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Lip defects due to tumor excision: Apropos of 899 cases
Oral Oncology (2007) 43, 204– 212
available at www.sciencedirect.com
journal homepage: http://intl.elsevierhealth.com/journals/oron/
Lip defects due to tumor excision: Apropos of 899 cases O. Papadopoulos a,b, P. Konofaos M. Frangoulis b, P. Karakitsos c a b c
a,*
, Z. Tsantoulas b, C. Chrisostomidis b,
Second Department of Propedeutic Surgery of Athens University, Laiko General Hospital of Athens, Attica, Greece Department of Plastic and Reconstructive Surgery, A Sygros Hospital, Athens, Greece Department of Cytopathology, University General Hospital ATTIKON, Athens, Greece
Received 4 February 2006; received in revised form 27 February 2006; accepted 27 February 2006 Available online 20 July 2006
KEYWORDS
Summary Reconstructive surgery of the lips after resection of tumors requires a complete understanding of the anatomy of this region. Most lip cancers remain localized and grow slowly, with a propensity for superficial rather than vertical spread. From January 1983 to December of 2005, 899 patients underwent reconstructive surgery for skin tumors involving the lips. SCCs were the most frequent skin tumors on male patients whereas BCCs were most common on the female patients. The lower lip was the anatomic zone most frequently involved in our series. Preoperative evaluation of the patients was performed in all cases. In the last five-years, we have performed preoperative fine needle aspiration (FNA) biopsy of the tumor. The FNA sample was then examined by ThinPrep technique (Cytolyt; Cytyc, Co, Boxborough, MA, USA). In our series, from the 550 patients who had a five-year follow-up we observed 62 recurrences of the primary tumor. The five-year recurrence rate was 11.28%. The aim of this retrospective study is to report our experience in the treatment of lips tumors with selective combination of treatment modalities. c 2006 Elsevier Ltd. All rights reserved.
Lip tumors; Lip defects; ThinPrep technique; Lip reconstruction
Introduction
Reconstructive surgery of lip defects due to cancer appears to be a unique challenge to the plastic surgeon because of * Corresponding author. Present address: 36, Megistis Street, Athens 11364, Attica, Greece. Tel.: +30 210 8668192/6977404371; fax: +30 210 8668192. E-mail address: [email protected] (P. Konofaos).
the prominent location, elegant form, and important functions of the lips. Resection of lip tumors causes both functional and aesthetic deficiencies. Oral competence, maximum oral aperture, mobility, sensation (when possible), and aesthetically pleasing results should be the aims of reconstruction of lip defects. Reconstructive surgery of the lips after resection of tumors requires a complete understanding of the anatomy of this region. The lips are a three-layered structure
1368-8375/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2006.02.015
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composed of skin, an inner layer of muscle, and mucosa. The major feature of both the upper and the lower lip is the vermilion, composed of modified mucosa that is devoid of minor salivary glands. The vermilion represents the mucocutaneous junction between the inner mucosa and outer skin, and it is of great cosmetic importance. The upper lip is composed of three units: two lateral wings and a median portion, the plithrum. The lower lip consists of a single unit demarcated superiorly by the vermilon–skin junction, inferiorly by the chin crease, and laterally by the nasolabial lines. The major muscle of the lips is the orbicularis oris, which provides sphincteric function for the oral cavity. Other associated muscles include the zygomaticus major and minor, levator anguli oris, levator labii superioris, depressor anguli oris, depressor labii inferioris, risorius, mentalis, buccinator, and platysma muscles.1,2 The vascular supply is via labial branches of the facial artery and veins, lying between the orbicularis musculature and oral mucosa.3 The sensory innervation is derived from the mandibular branch of the trigeminal nerve (V3) via the mental nerve. The motor nerves to the lip muscles arise from the buccal and marginal mandibular branches of cranial nerve VII. The lymphatic drainage of the upper lip and the lateral third of the lower lip are to submandibular nodes. The central third of the lower lip may drain into the submental lymph nodes on either side. Basal cell carcinomas (BCCs) develop almost exclusively on the upper lip,4 whereas squamous cell carcinomas (SCCs) develop almost exclusively on the lower lip. Only 5% of squamous cell cancers of the lips occur on the upper lip.4,5 In contrast to SCCs of the oral cavity, SCCs of the lips do not have the tendency for regional lymph node spread.6 Most lip cancers remain localized and grow slowly, with a propensity for superficial rather than vertical spread. Although recommendations on the margin of normal tissue
Figure 1
necessary for adequate cancer resection have varied, a 10 mm margin is generally preferred. The aim of this retrospective study is to report our experience in the treatment of lips tumors with selective combination of treatment modalities.
Patients and methods From January 1983 to December of 2005, 899 patients underwent reconstructive surgery for skin tumors involving the lips. All the patients referred to the Second Department of Propedeutic Surgery of Athens University and to the Department of Plastic Surgery of A Sygros Hospital. Five hundred and ninety patients were male and 309 patients were female. In our series, the majority of the patients (516 patients) (57.4%) were between 40 and 70 years old at the time of the operation. In addition, 326 patients (36.3%) were over 70 years old and only 57 patients (6.3%) were under 40 years old. SCCs were the most common tumors (467 patients), followed by BCCs (217 patients), actinic cheilitis (73 patients), leukoplakias (52 patients), hemangiomas (26 patients), malignant melanomas (10 patients) and other types (54 patients). In our series, SCCs were the most frequent skin tumors on male patients whereas BCCs were most common on the female patients. The lower lip was the anatomic zone most frequently involved in our series (Fig. 1). Preoperative evaluation of the patients was performed in all cases. In the last five-years, we have performed preoperative fine needle aspiration (FNA) biopsy of the tumor. The FNA sample was then examined by ThinPrep technique (Cytolyt; Cytyc, Co, Boxborough, MA, USA). The TP smears were prepared according to directions in the Operator’s Manual.7 TP smears of all FNA were prepared from needle risings obtained following FNA biopsies of lips tumors. The
Tumors types according to sex.
206 collected material was transferred to a vial containing fixating (Cytolyt; Cytyc, Co, Boxborough, MA, USA). The sample was then collected after centrifugation of the vial at 1300g for 5 min. In cases of bloody samples, additional Cytolyt solution washes were necessary, until the sample became clear. The supernatant was then discarded and the material was transferred to a vial with cytopreservative solution (PreservCyt; Cytyc, Co). The histological result of excised tumor sampling was considered the final diagnosis. We performed 170 FNA biopsies. The excised tissue was sent for pathological evaluation of the surgical margins. The excision was considered wide when the distance between the tumor and surgical margins was P1.0 cm. Surgical margins were defined as intralesional if they were microscopically positive; in these cases, we preferred to perform additional excision before starting the reconstruction. Selection of the appropriate operation for the patient was the most important part of the process, although skillful execution of the procedure was also of great importance. Resection of the tumor in each case consisted of removal of an adequate margin of healthy tissue, which depended on the location, the size of the tumor, and the general condition of the patient. Patients with cutaneous melanomas of the lips were treated by excision as deep and wide as indicated, even if reconstruction could be a problem after such an excision. The excision of the tumor was followed by a regional therapeutic lymph nodes dissection in the cases in which the lymph nodes involvement was clinically evident. We preferred to perform radical neck lymph nodes dissection rather than the modified radical neck dissection. Evaluation of lymph nodes status was done by physical examination and/ or CT of the head, neck and chest area in cases with palpable lymph nodes or positive sentinel lymph node. Since 2004, we have performed sentinel lymph node (SLN) biopsy on patients with SCCs, before tumor excision. We have also performed SLN biopsy on patients with malignant melanoma, since 2000. The elective reconstructive procedure was performed, in the majority of the cases, under local anesthesia with sedation or general anesthesia and infiltration with xylocaine 1% with epinephrine 1:200 000 so as to decrease bleeding. The choice of the appropriate reconstructive procedure was based upon three major criteria: the size and the location of the defect after tumor excision and the functional and aesthetic deficit created. The most important aesthetic landmark was the white roll. Reconstruction of lip defects must have under consideration the following principles: (1) Identical or similar tissues should be preferred for reconstruction. (2) The closer the donor tissue is situated to the defect, the more likely is the tissue match. (3) Natural landmarks and aesthetic units should always be restored. (4) Symmetry and balance are the mainstays of an aesthetic acceptable final result. (5) Proper realignment of the orbicularis oris fibers maintain the sphincter function and minimizes distortion during facial animation. When approaching lip reconstruction, one should first assess the lesion and attempt to determine the amount of mucosa, muscle, and skin that will be involved before incisions are made.
O. Papadopoulos et al. Free skin or mucosa grafts can be used for reconstruction of superficial lip defects or vermilion defects. On the other hand, full thickness lip defects can be restored with either wedge excision and direct closure if the defect is 61/3 of the lip length or local or regional flaps if the defect is >1/3 of the lip length.
Results Surgical procedures were tolerated well by all the patients. Average hospital stay was 1–2 days for the inpatients, including those who had staged operations or complication necessitating second operation. The results were estimated from an oncological, functional, and aesthetic point of view. Using the TP technique adequate material was observed in 162 out of 170 examined lesions. The TP technique successfully established the benign (15 actinic cheilitis, 10 leukoplakias, seven labial lentigines) or malignant (70 SCCs, 54 BCCs, four malignant melanomas) nature of the lesions in the 160 cases out of 162 cases with adequate material (Fig. 2). The eight cases with inadequate material included one case of SCC, two cases of actinic cheilitis, two cases of leukoplakia, two cases of kaposi sarcomas and one case of metastatic adenocarcinoma. In the two cases of SCCs TP technique revealed only normal cells. TP technique results were correlated with the final histological diagnosis. Of the 73 cases of SCCs confirmed by histological diagnosis, 70 were also revealed by TP. Of the 54 cases of BCCs confirmed by histological diagnosis, 54 were also revealed by TP. Of the 17 cases of Actinic Cheilitis confirmed by histological diagnosis, 15 were also revealed by TP. Of the 12 cases of leukoplakias confirmed by histological diagnosis, 10 were also revealed by TP. In five patients with SCCs the histological examination was repeated two times so that the pathologist could reach a diagnosis which was also revealed by TP. The reliability of the TP technique was evaluated by the determination of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy (OA) (Tables 1 and 2). We performed 10 radical neck lymph nodes dissections. SLN biopsy was done on 15 patients with SCCs (11 patients) and malignant melanoma (four patients). The result was negative on 10 cases. The next step of the operation was the repair of the defect Excision of the tumor was followed by reconstruction of the defect. We performed wedge excision in the form of a V or W and direct closure on 573 cases, total vermilioectomy on 291 cases, various types of flaps on 120 cases and full thickness skin grafts on two cases. All the above are summarized in Table 3. Patients were examined at least three times in the first postoperative year and one time from second to fifth postoperative year during routine follow-up. Only 550 patients had sufficient medical records with a five year follow-up, while for 100 patients follow-up was short. There was insufficient data for 249 patients. Out of stayed patients combined with low socioeconomic and mental status patients were the main reasons for this high percentage of insufficient medical records, concerning our study. Follow-up
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Figure 2 (a) Basal cell carcinoma of the lip (PAP ·40, Papanicolaou Stain, magnification ·40). (b) Squamous cell carcinoma of the lip (PAP ·40, Papanicolaou Stain, magnification ·40). (c) Malignant melanoma of the lip (PAP ·40, Papanicolaou Stain, magnification ·40).
Table 1 Correlation between TP technique results and histological diagnosis
Table 3
Type of surgical treatment
Patients
Results
TP
SCCs BCCs Actinic chelitis Leukoplakias Labial lentigines Malignant melanomas Kaposi sarcomas Metastatic adenocarcinoma Inadequate material With normal limits
70 54 15 10 7 4 0 0 8 2
Excision–direct closure Vermilioectomies Flaps (1) Local Abbe’s flap Estlander’s flap Dufourmentel’s flap Nasolabial flap Various (2) Regional Frontal Platysma Pectoralis major flap Split thickness skin graft
573 291 120
Total
Histological diagnosis 73 54 17 12 7 4 2 1 0 0 170
was done on all patients mostly by the operating surgeon. All the above are summarized in Table 4. Complications were divided into two groups: (1) Early complications, which occurred during the first month. We observed three patients with hematoma formation, and 15 patients with wound infection. (2) Late complications, which occurred after the first month. We noticed one death from a recurrent SCC. Moreover, we observed 62 patients Table 2
Table 4
Surgical procedures
66 20 21 7 3 1 1 1 2
Follow-up of the patients Patients
Five-year follow-up Insufficient medical records Follow-up < 1 year
550 249 100
TP technique diagnostic accuracy
Type of diagnosis
Sensitivity
Specifity
PPV
NPV
OA
TP technique
98.68%
100.00%
100.00%
83.33%
98.76%
208
O. Papadopoulos et al.
Figure 3
Five-year disease free survival rate.
with local recurrence of the primary tumor. In our series, the five-year disease free survival rate was 88.72% (Fig. 3).
Discussion The most frequent type of skin cancer occurring on the lips is the SCC followed by the BCC. The lower lip is the most frequent location involved. The primary goal of surgical treatment of lip tumors is the three-dimensional tumor resection with histological clear margins. This goal has to be balanced, however, with an acceptable functional and aesthetic result. Preoperative either punch biopsy and/or fine needle aspiration (FNA) biopsy of the tumor can be used with success in the preoperative evaluation of the histological type of the tumor and at the planning of the appropriate treatment. Since 2000, we have performed in all of our patients fine needle aspiration (FNA) biopsy of the tumor. ThinPrep (TP) technique (Cytolyt; Cytyc, Co, Boxborough, MA, USA) was used for the processing of FNA biopsy material. ThinPrep processor mixing action permits the preparation of multiple slides of a relatively consistent appearance; consequently, slides prepared for immunostaining from malignant aspirates can be presumed to contain diagnostic cells. In the preparation of a TP slide, aspirated material is rinsed directly into Cytolyt, a proprietary liquid fixative medium, resulting in immediate wet fixation of the cells.8 Furthermore, the mechanical forces associated with manual smearing are eliminated. TP processing also includes a mixing/ homogenization step, which could explain the smaller clusters and increased number of single cells seen on TP smears. The loss of background material on TP-prepared aspirates is one important difference between conventional smears and TP slides. On TP, single-cell necrosis is observed less frequently, and nucleoli are more prominent. In our series, in five patients with SCCs the histological examination of the excised tumor sampling was repeated two times in order to reach a final diagnosis. For the second
histological examination, pathologists performed deeper incisions on the tumor sample. The final histological diagnosis in these cases was in agreement with the results of TP technique. This could be explained by the fact that the TP technique eliminates the number of inflammatory cells and single cell necrosis. Subsequently, the complementarity of TP technique with histological diagnosis is confirmed; this combination leads to a more accurate final diagnosis and to a more appropriate preoperative evaluation. Of course, additional studies will be required to confirm our findings. In general, cervical metastasis is seen in less than 8% of patients at the time of presentation. The excision of the tumor was followed by a regional therapeutic lymph nodes dissection in the cases in which the lymph nodes involvement was clinically evident. In our series, we performed 10 therapeutic radical neck dissections on patients with clinically evident lymph nodes involvement. One of these patients died after multiple distant metastases. Postoperative radiotherapy was administered to these patients. According to Khurana et al.9 postoperative radiotherapy is not associated with improved disease control. We believe that complete surgical resection is the treatment of choice for lip skin cancers. Failure to excise the tumor is the main cause of local recurrence. The use of the Moh’s micrographic surgery for excision of lip tumors has been suggested by many authors as the method of choice.10,11 This technique was first described by Dr. Frederic Mohs in 194112 and was based on the principle that when zinc chloride was applied to tissue, the tissue was fixed and the tumor could be shaved off horizontally, after which 100% of the resection margins could be examined microscopically. Moh’s is used for large skin cancers, recurrent skin cancers, skin cancer in difficult locations (such as lips, pennies, lower eyelid, nose, fingers, etc.), and very poorly defined skin cancers. Even though Moh’s micrographic surgery provides low recurrence rates, recurrences still can occur after treatment with Moh’s technique, where theoretically 100% of the resection margins are viewed.13–17
Lip defects due to tumor excision Eliezri et al., and Dzubow both report cases where the scar tissue (in case of biopsy scar or a recurrent BCC) is not completely excised and therefore tumor is missed.13,14 Moreover, skin carcinomas may sometimes recrudesce, independently of the clear limits of the lesion. We prefer to remove completely the tumor en block with a safety margin of adjacent normal tissue in all directions, minimizing the probability of recurrence. Since 2000, we have used sentinel lymph node (SLN) biopsy in cases of cutaneous melanoma of the lips. After 2004 we have used SLN biopsy in cases of neglected SCCs of the lips (diameter P 2 cm). The technique of intraoperative lymphatic mapping and selective lymphadenectomy was introduced for melanoma patients by Morton et al.18 Because of the successful results with melanoma, investigators tried to incorporate the technique into the treatment of several other solid skin tumors such as SSCs. The risk of regional lymph node metastases is 4% for T1 lesions and 20% for T2 or greater lesions. Because of the relatively low incidence of nodal metastasis in T1 lesions, primary excision of the tumor with adequate margins is often sufficient for cure. We prefer the SLN biopsy especially to the youngest patients with central tumor location, from an unnecessary lymph node dissection of the area. The ability of sentinel lymphadenectomy to identify regionally metastatic cutaneous SCC remains to be further clarified.19 After tumor resection, the aims of reconstruction must be to maintain oral competence, maximum oral aperture, mobility, sensation when possible, and maximize aesthetic result. The restoration of a natural appearance should not be the only mainstay of reconstruction; adequate lip function is of equal importance. When defects involve more than one lip, more complex reconstructive procedures are required. The lip curtain must be of adequate height, sensated and possess adequate extrinsic and intrinsic musculature. The lower vermilion is the most common site of neoplastic lesions since it is the target of solar radiation injury. Small lesions can be excised in fusiform fashion and closed primarily. Incisions should be placed in the radially oriented relaxed skin tension lines.3 When the defect is limited to less than one third of the lower vermilion, a vermilion–muscle advancement flap based on the axial labial artery may be used to resurface the area of the defect.20 When simple advancement is inadequate, a triangular musculomucosal V–Y advancement flap can be used. Kawamoto21 described a vermilion lip switch flap for correction of cases involving large defects of vermilion. A transverse, centrally based musculomucosal flap is designed on the lower lip and then is elevated and turned upward 180 and sutured into the deficient portion of the upper lip. The flap is divided at 12–14 days. In cases of extensive premalignant lesions of the lip vermilioectomy is indicated. In this operation the vermilion is resected from the white roll to the contact area of the upper and lower lip. Repair of the defect is done by advancement of labial mucosa, which is then redraped over the underlying orbicularis musculature. The plane of dissection is between the uninvolved mucosa and underlying musculature. This method decreases the inward retraction of the lip, which occurs with primary closure, avoiding irritation by the lower lip hairs, and producing a better contour.
209 Tongue mucosal flaps22–25 have been described for vermilion reconstruction. They are rarely preferred because they are an unpleasant experience for the patient. Reconstruction of lower lip defects is eased by the lack of a dominant central structure such as the philtrum, and the greater laxicity of soft tissues. These properties allow for better mobilization of tissues adjacent to the defect without causing obvious distortion. Defects 61/3 of the horizontal length of the lower lip may be repaired with direct closure in three layers: mucosa, muscle, and skin. The patient’s age, elasticity, and redundancy of adjacent soft tissue determine the size of the defect that can be closed directly. In our series, we used the rhomboid-shaped transposition flap of Dufourmentel26 for cutaneous small defects of the upper or lower lip. The flap is located next to the primary defect in a way that facilitates direct closure of the donor site. Four flaps are mainly used for repair of defects with length between 1/3 and 2/3 of the horizontal length of the lower lip (medium defects). These are the Abbe flap, the Karapandzic flap, the Bernard–Burow’s procedure and the Estlander flap. The Abbe flap27 (Fig. 4) can be used for medium defects which do not involve the commissure and in cases where there is sufficient lower lip tissue for reconstruction. The flap is designed at the junction of the middle and lateral thirds of the upper lip so that neither the philtrum nor the commissure is affected. Then the flap is elevated and rotated along the vascular pedicle so as to fill the defect. The main potential disadvantages of this procedure are: (1) the total flap loss either intraoperatively or postoperatively, (2) the fact that it is a two stage reconstruction because the pedicle of the flap is divided after 14–21 days and the patient remains for this period of time with his lips apposed. The aesthetic result is generally better than that seen with the Bernard–Burow’s procedure and the Karapandzic flap. The Karapandzic flap28 is mainly used for medium lower lip defects that do not require new lip tissue for reconstruction and that are either located centrally or more laterally where they involve a portion of the commissure. The incision is carried circumorally to the alar base bilaterally. The incision is made in full thickness through skin, muscle, and mucosa medially. Laterally, at the level of the commissures the skin is incised only down to subcutaneous tissue. The flaps are rotated inward to fill the defect. The oral sphincter remains intact and functional after this procedure. The main potential disadvantages of this procedure are: (1) unsightly scarring, (2) the potential for microstomia which can be particularly troublesome to patients who use dentures. The Bernard–Burow’s procedure is used for reconstruction of the lower lip in cases where there is not adequate lip soft tissue after tumor excision. In the original operation, full-thickness triangles of cheek tissue are excised on each side of the upper lip, providing relief room for the lower cheek flaps to be advanced medially. This original operation has undergone multiple modifications which aim at improving the functional and aesthetic result. Main potential disadvantages of this procedure are: (1) incomplete recovery of sensation and mobility in the lip tissue, (2) scar contracture at the commissure causing an unusual ‘smiley
210
O. Papadopoulos et al.
Figure 4 (a) Squamous cell carcinoma of the lower lip. (b) Abbe flap and its pedicle. (c) Final result. (d) Natural appearance of the lower lip.
face’, (3) color mismatch of the reconstructed vermilion with adjacent vermilion, (4) drooling. Through modifications by Freeman29 and Webster et al.30 skin and subcutaneous tissue are excised in a more lateral position placing the scar in the nasolabial fold and resulting in improved postoperative sensation of the reconstructed lip. The Estlander flap is used for reconstructions of defects that involve the commissure and is impossible to be repaired by the Karapandzic flap. It is a laterally based lip switch flap, pivoting around the corner of the mouth. The flap is designed on the upper lateral lip at a size equivalent to one half of the lower lip defect. This is a one step procedure and it has the same potential disadvantages like Abbe procedure with one main exception, the rounded appearance with poor angle definition of the commissure. Reconstruction of defects P2/3 of the horizontal length of the lower lip (large defects) is a challenging problem. A reasonable degree of oral function and competence are the mainstays in this type of reconstruction. When there is sufficient remaining lip or cheek tissue the Bernard’s procedure is the method of choice for reconstruction of large lower lip defects. Another choice is the Karapandzic flap which is used for repair of medially located large lower lip defects. In massive lip defects free tissue transfer or a distant pedi-
cle flap provides the most consistent results. We prefer the use of the pedicled musculocutaneous flap of platysma for filling such defects. In cases where the defect involves the mandible, an osteomusculocutaneous flap (either free or pedicled) should be used for reconstruction. We use the pedicled musculocutaneous flap of pectoralis major muscle combined with the 4th rib for reconstruction of this type of defects (Fig. 5). Upper lip defects due to tumor excision are less common than lower ones. Reconstruction of upper lip defects is more difficult due to the presence of central structures-like nose, columella. Regional and distant flaps for repair of upper lip defects may provide more acceptable functional and aesthetic results than comparable procedures for the lower lip. Reconstruction of small upper lip defects (61/3 of the horizontal length of the lip) depends on the location of the defect. When the defect involves only the upper lip tissue, with intact vermilion, a nasolabial flap from the ipsilateral side can be used for repair of the defect. The flap (skin and subcutaneous tissue) is either superiorly or inferiorly based and is rotated into place from a position adjacent to the defect. The donor side is closed primarily along the nasolabial fold. Laterally located defects can be closed with primary closure. Medially located defects can be closed with
Lip defects due to tumor excision
211
Figure 5 (a) Squamous cell carcinoma of the lower lip involving the mandible. (b) Resection of the tumor and part of the mandible. (c) Pedicled musculocutaneous flap of pectoralis major muscle combined with the fourth rib for reconstruction of the defect. (d) Final result.
direct closure after perialar crescentic skin excisions and release of upper buccal sulcus to allow medial advancement of the lip tissue. The excision involves skin and subcutaneous tissue. Location of the defect is the main criterion for the type of reconstruction of medium defects of the upper lip (>1/3 and 62/3 of the horizontal length of the lip). Centrally located defects can be closed after perialar crescentic excisions either with primary closure if the defect is <1/2 of the horizontal length of the upper lip or with the use of
Figure 6
an Abbe flap or a Karapandzic flap for defects >1/2 of the horizontal length of the upper lip. We believe that for these defects the use of an Abbe flap is the best choice for reconstruction due to better functional and aesthetic results. Laterally positioned medium defects must be considered in the context of presence or absence of commissure involvement. When the commissure is not involved an Abbe flap can be used for repair of the defect. An Estlander flap can be used for filling of the defect when there is involvement of the commissure. If the defect involves the philtrum, the combi-
Five-year recurrence rate according to type of surgical treatment.
212 nation of a controlateral perialar crescentic excision with the use of an Estlander flap is the method of choice for repair of the defect. Repairing of large upper lip defects (>2/3 of the horizontal length of the lip) depends on the adequacy or not of the adjacent cheek tissues. When there are adequate adjacent cheek tissues for reconstruction the method of choice is the Bernard–Burow’s procedure. The upper lip is replaced with midcheek tissue. Burow’s triangles are excised laterally to the lower lip, on both sides, and laterally to each alar base. The triangular excisions involve only skin and subcutaneous tissue. The cheek tissue is then advanced medially to create the new upper lip. Vermilion reconstruction is undertaken using mucosa from the advanced cheek flaps. Laterally located large upper lip defects can be repaired with the combination of a unilateral upper lip Bernard–Burow’s procedure and a controlateral perialar crescentic excision. When there is inadequate adjacent cheek tissue for reconstruction free tissue transfer or a distant pedicle flap can be used for filling the defect. A successful reconstruction should derive from careful preoperative planning, knowledge of the anatomy, and use of sound surgical techniques. Flawless operative technique is important for a successful outcome. The use of prophylactic perioperative antibiotics is imperative. Gentle handling of tissues, meticulous hemostasis, and judicious placement of drains are of paramount importance. Careful postoperative wound inspection is necessary, for the early detection of septic complications or wound healing impairment. In our series, from the 550 patients who had a five-year follow-up we observed 62 recurrences of the primary tumor. The five-year recurrence rate was 11.28%. According to type of surgical treatment, surgical excision followed by direct closure was the type of surgery with the highest five-year recurrence rate (10.82%), even though the histological diagnosis was negative for positive margins in the majority of cases (Fig. 6). We believe that these findings were due to limited margin of adjacent normal tissue and the low grade of differentiation of these tumors. Ancillary studies are needed to confirm our findings. In conclusion, we suggest that postoperatively, patients should have systemic annual follow-ups. Individual risk assessment should be routine, and those at a particular high risk, such as those with previous skin tumors, require more intensive monitoring. It is essential for the plastic and reconstructive surgeon to be familiar with the particular procedures used in eyelid reconstruction. He should have close cooperation with the patient to succeed in performing a suitable outcome.
References 1. Freilinger G, Gruber H, Happak W, Pechmann U. Surgical anatomy of the mimic muscle system and the facial nerve: Importance for reconstructive and aesthetic surgery. Plast Reconstr Surg 1987;80:686–90. 2. Zide BM. Deformities of the lips and cheeks. In: McCarthy JG, editor. Plastic Surgery, Vol. 3. Philadelphia: WB Saunders Company; 1990. p. 2009–56. 3. Galyon SW, Frodel JL. Lip and perioral defects. Otolaryngol Clin North Am 2001;34:647–66.
O. Papadopoulos et al. 4. Zitsch RP. Carcinoma of the lip. Otolaryngol Clin North Am 1993;26:265–77. 5. Cruse CW, Radocha RF. Squamous cell carcinoma of the lip. Plast Reconstr Surg 1987;80:787–91. 6. Luce EA. Carcinoma of the lower lip. Surg Clin North Am 1986;66:3–11. 7. Cytyc ThinPrep 2000 Operator’s Manual, . Boxborough (MA): Cytyc; 1997. 8. Silverman JF, Finley JL, O’Brien KF, et al. Diagnostic accuracy and role of immediate interpretation of fine needle aspiration biopsy specimens from various sites. Acta Cytol 1989;33:791–6. 9. Khurana VG, Mentis DH, O’Brien CJ, Hurst TL, Stevens GN, Packham NA. Parotid and neck metastases from cutaneous squamous cell carcinoma of the head and neck. Am J Surg 1995;170(5):446–50. 10. Mohs F. Chemosurgery: A microscopically controlled method of cancer excision. Arch Surg 1941;42:279–95. 11. Baker NJ, Webb AA, Macpherson D. Surgical management of cutaneous squamous cell carcinoma of the head and neck. Br J Oral Maxillofac Surg 2001;39:87–90. 12. Zide MF, Adnot J. Lower lip cancer: Mohs micrographic surgery and reconstruction as a multidisciplinary effort. J Oral Maxillofac Surg 1997;55:818–25. 13. Eliezri YD, Cohen PR. Cancer recurrence following Mohs micrographic surgery: A mechanism of tumor persistence. Plast Reconstr Surg 1992;90:121–5. 14. Dzubow LM. False-negative tumor-free margins following Mohs surgery. J Dermatol Surg Oncol 1988;14:600–2. 15. Smeets NW, Stavast-Kooy AJ, Krekels GA, et al. Adjuvant cytokeratin staining in Mohs micrographic surgery for basal cell carcinoma. Dermatol Surg 2003;29:375–7. 16. Hruza GJ. Mohs micrographic surgery local recurrences. J Dermatol Surg Oncol 1994;20:573–7. 17. Rapini RP. Pitfalls of Mohs micrographic surgery. J Am Acad Dermatol 1990;22:681–6. 18. Morton DL, Wen DR, Wong JH, et al. Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg 1992;127:392–9. 19. Kontio R, Leivo I, Leppanen E, Atula T. Sentinel lymph node biopsy in oral cavity squamous cell carcinoma without clinically evident metastasis. Head Neck 2004;26:16–21. 20. Goldstein MH. A tissue expanding vermilion myocutaneous flap for lip repair. Plast Reconstr Surg 1984;73:768–70. 21. Kawamoto HK. Correction of major defects of the vermilion with a cross-lip vermilion flap. Plast Reconstr Surg 1979;64:315–8. 22. Guerrero-Santos J. Use of a tongue flap in secondary correction of cleft lips. Plast Reconstr Surg 1969;44:368–71. 23. Jackson IT. Use of tongue flaps to resurface lip defects and close palatal fistulae in children. Plast Reconstr Surg 1972;49:537–41. 24. Guerrero-Santos J, Castaneda A, Barba JA. Surgery for correction of labial angiomas. Arch Surg 1967;94:728–33. 25. Zarem HA, Greer Jr DM. Tongue flap for reconstruction of the lips after electrical burns. Plast Reconstr Surg 1974;53:310–2. 26. Dufourmentel G. Le fermetur des pertes de substance cutanee limitees. Ann Chir Plast 1962;7:61. 27. Abbe R. A new plastic operation for the relief of deformity due to double harelip. Plast Reconstr Surg 1968;42:481–3. 28. Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:93–7. 29. Freeman BS. Myoplastic modification of the Bernard cheiloplasty. Plast Reconstr Surg 1958;21:453–60. 30. Webster RC, Coffey RJ, Kelleher RE. Total and partial reconstruction of the lower lip with innervated muscle bearing flaps. Plast Reconstr Surg 1960;25:360–71.
available at www.sciencedirect.com
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Lip defects due to tumor excision: Apropos of 899 cases O. Papadopoulos a,b, P. Konofaos M. Frangoulis b, P. Karakitsos c a b c
a,*
, Z. Tsantoulas b, C. Chrisostomidis b,
Second Department of Propedeutic Surgery of Athens University, Laiko General Hospital of Athens, Attica, Greece Department of Plastic and Reconstructive Surgery, A Sygros Hospital, Athens, Greece Department of Cytopathology, University General Hospital ATTIKON, Athens, Greece
Received 4 February 2006; received in revised form 27 February 2006; accepted 27 February 2006 Available online 20 July 2006
KEYWORDS
Summary Reconstructive surgery of the lips after resection of tumors requires a complete understanding of the anatomy of this region. Most lip cancers remain localized and grow slowly, with a propensity for superficial rather than vertical spread. From January 1983 to December of 2005, 899 patients underwent reconstructive surgery for skin tumors involving the lips. SCCs were the most frequent skin tumors on male patients whereas BCCs were most common on the female patients. The lower lip was the anatomic zone most frequently involved in our series. Preoperative evaluation of the patients was performed in all cases. In the last five-years, we have performed preoperative fine needle aspiration (FNA) biopsy of the tumor. The FNA sample was then examined by ThinPrep technique (Cytolyt; Cytyc, Co, Boxborough, MA, USA). In our series, from the 550 patients who had a five-year follow-up we observed 62 recurrences of the primary tumor. The five-year recurrence rate was 11.28%. The aim of this retrospective study is to report our experience in the treatment of lips tumors with selective combination of treatment modalities. c 2006 Elsevier Ltd. All rights reserved.
Lip tumors; Lip defects; ThinPrep technique; Lip reconstruction
Introduction
Reconstructive surgery of lip defects due to cancer appears to be a unique challenge to the plastic surgeon because of * Corresponding author. Present address: 36, Megistis Street, Athens 11364, Attica, Greece. Tel.: +30 210 8668192/6977404371; fax: +30 210 8668192. E-mail address: [email protected] (P. Konofaos).
the prominent location, elegant form, and important functions of the lips. Resection of lip tumors causes both functional and aesthetic deficiencies. Oral competence, maximum oral aperture, mobility, sensation (when possible), and aesthetically pleasing results should be the aims of reconstruction of lip defects. Reconstructive surgery of the lips after resection of tumors requires a complete understanding of the anatomy of this region. The lips are a three-layered structure
1368-8375/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2006.02.015
Lip defects due to tumor excision
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composed of skin, an inner layer of muscle, and mucosa. The major feature of both the upper and the lower lip is the vermilion, composed of modified mucosa that is devoid of minor salivary glands. The vermilion represents the mucocutaneous junction between the inner mucosa and outer skin, and it is of great cosmetic importance. The upper lip is composed of three units: two lateral wings and a median portion, the plithrum. The lower lip consists of a single unit demarcated superiorly by the vermilon–skin junction, inferiorly by the chin crease, and laterally by the nasolabial lines. The major muscle of the lips is the orbicularis oris, which provides sphincteric function for the oral cavity. Other associated muscles include the zygomaticus major and minor, levator anguli oris, levator labii superioris, depressor anguli oris, depressor labii inferioris, risorius, mentalis, buccinator, and platysma muscles.1,2 The vascular supply is via labial branches of the facial artery and veins, lying between the orbicularis musculature and oral mucosa.3 The sensory innervation is derived from the mandibular branch of the trigeminal nerve (V3) via the mental nerve. The motor nerves to the lip muscles arise from the buccal and marginal mandibular branches of cranial nerve VII. The lymphatic drainage of the upper lip and the lateral third of the lower lip are to submandibular nodes. The central third of the lower lip may drain into the submental lymph nodes on either side. Basal cell carcinomas (BCCs) develop almost exclusively on the upper lip,4 whereas squamous cell carcinomas (SCCs) develop almost exclusively on the lower lip. Only 5% of squamous cell cancers of the lips occur on the upper lip.4,5 In contrast to SCCs of the oral cavity, SCCs of the lips do not have the tendency for regional lymph node spread.6 Most lip cancers remain localized and grow slowly, with a propensity for superficial rather than vertical spread. Although recommendations on the margin of normal tissue
Figure 1
necessary for adequate cancer resection have varied, a 10 mm margin is generally preferred. The aim of this retrospective study is to report our experience in the treatment of lips tumors with selective combination of treatment modalities.
Patients and methods From January 1983 to December of 2005, 899 patients underwent reconstructive surgery for skin tumors involving the lips. All the patients referred to the Second Department of Propedeutic Surgery of Athens University and to the Department of Plastic Surgery of A Sygros Hospital. Five hundred and ninety patients were male and 309 patients were female. In our series, the majority of the patients (516 patients) (57.4%) were between 40 and 70 years old at the time of the operation. In addition, 326 patients (36.3%) were over 70 years old and only 57 patients (6.3%) were under 40 years old. SCCs were the most common tumors (467 patients), followed by BCCs (217 patients), actinic cheilitis (73 patients), leukoplakias (52 patients), hemangiomas (26 patients), malignant melanomas (10 patients) and other types (54 patients). In our series, SCCs were the most frequent skin tumors on male patients whereas BCCs were most common on the female patients. The lower lip was the anatomic zone most frequently involved in our series (Fig. 1). Preoperative evaluation of the patients was performed in all cases. In the last five-years, we have performed preoperative fine needle aspiration (FNA) biopsy of the tumor. The FNA sample was then examined by ThinPrep technique (Cytolyt; Cytyc, Co, Boxborough, MA, USA). The TP smears were prepared according to directions in the Operator’s Manual.7 TP smears of all FNA were prepared from needle risings obtained following FNA biopsies of lips tumors. The
Tumors types according to sex.
206 collected material was transferred to a vial containing fixating (Cytolyt; Cytyc, Co, Boxborough, MA, USA). The sample was then collected after centrifugation of the vial at 1300g for 5 min. In cases of bloody samples, additional Cytolyt solution washes were necessary, until the sample became clear. The supernatant was then discarded and the material was transferred to a vial with cytopreservative solution (PreservCyt; Cytyc, Co). The histological result of excised tumor sampling was considered the final diagnosis. We performed 170 FNA biopsies. The excised tissue was sent for pathological evaluation of the surgical margins. The excision was considered wide when the distance between the tumor and surgical margins was P1.0 cm. Surgical margins were defined as intralesional if they were microscopically positive; in these cases, we preferred to perform additional excision before starting the reconstruction. Selection of the appropriate operation for the patient was the most important part of the process, although skillful execution of the procedure was also of great importance. Resection of the tumor in each case consisted of removal of an adequate margin of healthy tissue, which depended on the location, the size of the tumor, and the general condition of the patient. Patients with cutaneous melanomas of the lips were treated by excision as deep and wide as indicated, even if reconstruction could be a problem after such an excision. The excision of the tumor was followed by a regional therapeutic lymph nodes dissection in the cases in which the lymph nodes involvement was clinically evident. We preferred to perform radical neck lymph nodes dissection rather than the modified radical neck dissection. Evaluation of lymph nodes status was done by physical examination and/ or CT of the head, neck and chest area in cases with palpable lymph nodes or positive sentinel lymph node. Since 2004, we have performed sentinel lymph node (SLN) biopsy on patients with SCCs, before tumor excision. We have also performed SLN biopsy on patients with malignant melanoma, since 2000. The elective reconstructive procedure was performed, in the majority of the cases, under local anesthesia with sedation or general anesthesia and infiltration with xylocaine 1% with epinephrine 1:200 000 so as to decrease bleeding. The choice of the appropriate reconstructive procedure was based upon three major criteria: the size and the location of the defect after tumor excision and the functional and aesthetic deficit created. The most important aesthetic landmark was the white roll. Reconstruction of lip defects must have under consideration the following principles: (1) Identical or similar tissues should be preferred for reconstruction. (2) The closer the donor tissue is situated to the defect, the more likely is the tissue match. (3) Natural landmarks and aesthetic units should always be restored. (4) Symmetry and balance are the mainstays of an aesthetic acceptable final result. (5) Proper realignment of the orbicularis oris fibers maintain the sphincter function and minimizes distortion during facial animation. When approaching lip reconstruction, one should first assess the lesion and attempt to determine the amount of mucosa, muscle, and skin that will be involved before incisions are made.
O. Papadopoulos et al. Free skin or mucosa grafts can be used for reconstruction of superficial lip defects or vermilion defects. On the other hand, full thickness lip defects can be restored with either wedge excision and direct closure if the defect is 61/3 of the lip length or local or regional flaps if the defect is >1/3 of the lip length.
Results Surgical procedures were tolerated well by all the patients. Average hospital stay was 1–2 days for the inpatients, including those who had staged operations or complication necessitating second operation. The results were estimated from an oncological, functional, and aesthetic point of view. Using the TP technique adequate material was observed in 162 out of 170 examined lesions. The TP technique successfully established the benign (15 actinic cheilitis, 10 leukoplakias, seven labial lentigines) or malignant (70 SCCs, 54 BCCs, four malignant melanomas) nature of the lesions in the 160 cases out of 162 cases with adequate material (Fig. 2). The eight cases with inadequate material included one case of SCC, two cases of actinic cheilitis, two cases of leukoplakia, two cases of kaposi sarcomas and one case of metastatic adenocarcinoma. In the two cases of SCCs TP technique revealed only normal cells. TP technique results were correlated with the final histological diagnosis. Of the 73 cases of SCCs confirmed by histological diagnosis, 70 were also revealed by TP. Of the 54 cases of BCCs confirmed by histological diagnosis, 54 were also revealed by TP. Of the 17 cases of Actinic Cheilitis confirmed by histological diagnosis, 15 were also revealed by TP. Of the 12 cases of leukoplakias confirmed by histological diagnosis, 10 were also revealed by TP. In five patients with SCCs the histological examination was repeated two times so that the pathologist could reach a diagnosis which was also revealed by TP. The reliability of the TP technique was evaluated by the determination of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy (OA) (Tables 1 and 2). We performed 10 radical neck lymph nodes dissections. SLN biopsy was done on 15 patients with SCCs (11 patients) and malignant melanoma (four patients). The result was negative on 10 cases. The next step of the operation was the repair of the defect Excision of the tumor was followed by reconstruction of the defect. We performed wedge excision in the form of a V or W and direct closure on 573 cases, total vermilioectomy on 291 cases, various types of flaps on 120 cases and full thickness skin grafts on two cases. All the above are summarized in Table 3. Patients were examined at least three times in the first postoperative year and one time from second to fifth postoperative year during routine follow-up. Only 550 patients had sufficient medical records with a five year follow-up, while for 100 patients follow-up was short. There was insufficient data for 249 patients. Out of stayed patients combined with low socioeconomic and mental status patients were the main reasons for this high percentage of insufficient medical records, concerning our study. Follow-up
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Figure 2 (a) Basal cell carcinoma of the lip (PAP ·40, Papanicolaou Stain, magnification ·40). (b) Squamous cell carcinoma of the lip (PAP ·40, Papanicolaou Stain, magnification ·40). (c) Malignant melanoma of the lip (PAP ·40, Papanicolaou Stain, magnification ·40).
Table 1 Correlation between TP technique results and histological diagnosis
Table 3
Type of surgical treatment
Patients
Results
TP
SCCs BCCs Actinic chelitis Leukoplakias Labial lentigines Malignant melanomas Kaposi sarcomas Metastatic adenocarcinoma Inadequate material With normal limits
70 54 15 10 7 4 0 0 8 2
Excision–direct closure Vermilioectomies Flaps (1) Local Abbe’s flap Estlander’s flap Dufourmentel’s flap Nasolabial flap Various (2) Regional Frontal Platysma Pectoralis major flap Split thickness skin graft
573 291 120
Total
Histological diagnosis 73 54 17 12 7 4 2 1 0 0 170
was done on all patients mostly by the operating surgeon. All the above are summarized in Table 4. Complications were divided into two groups: (1) Early complications, which occurred during the first month. We observed three patients with hematoma formation, and 15 patients with wound infection. (2) Late complications, which occurred after the first month. We noticed one death from a recurrent SCC. Moreover, we observed 62 patients Table 2
Table 4
Surgical procedures
66 20 21 7 3 1 1 1 2
Follow-up of the patients Patients
Five-year follow-up Insufficient medical records Follow-up < 1 year
550 249 100
TP technique diagnostic accuracy
Type of diagnosis
Sensitivity
Specifity
PPV
NPV
OA
TP technique
98.68%
100.00%
100.00%
83.33%
98.76%
208
O. Papadopoulos et al.
Figure 3
Five-year disease free survival rate.
with local recurrence of the primary tumor. In our series, the five-year disease free survival rate was 88.72% (Fig. 3).
Discussion The most frequent type of skin cancer occurring on the lips is the SCC followed by the BCC. The lower lip is the most frequent location involved. The primary goal of surgical treatment of lip tumors is the three-dimensional tumor resection with histological clear margins. This goal has to be balanced, however, with an acceptable functional and aesthetic result. Preoperative either punch biopsy and/or fine needle aspiration (FNA) biopsy of the tumor can be used with success in the preoperative evaluation of the histological type of the tumor and at the planning of the appropriate treatment. Since 2000, we have performed in all of our patients fine needle aspiration (FNA) biopsy of the tumor. ThinPrep (TP) technique (Cytolyt; Cytyc, Co, Boxborough, MA, USA) was used for the processing of FNA biopsy material. ThinPrep processor mixing action permits the preparation of multiple slides of a relatively consistent appearance; consequently, slides prepared for immunostaining from malignant aspirates can be presumed to contain diagnostic cells. In the preparation of a TP slide, aspirated material is rinsed directly into Cytolyt, a proprietary liquid fixative medium, resulting in immediate wet fixation of the cells.8 Furthermore, the mechanical forces associated with manual smearing are eliminated. TP processing also includes a mixing/ homogenization step, which could explain the smaller clusters and increased number of single cells seen on TP smears. The loss of background material on TP-prepared aspirates is one important difference between conventional smears and TP slides. On TP, single-cell necrosis is observed less frequently, and nucleoli are more prominent. In our series, in five patients with SCCs the histological examination of the excised tumor sampling was repeated two times in order to reach a final diagnosis. For the second
histological examination, pathologists performed deeper incisions on the tumor sample. The final histological diagnosis in these cases was in agreement with the results of TP technique. This could be explained by the fact that the TP technique eliminates the number of inflammatory cells and single cell necrosis. Subsequently, the complementarity of TP technique with histological diagnosis is confirmed; this combination leads to a more accurate final diagnosis and to a more appropriate preoperative evaluation. Of course, additional studies will be required to confirm our findings. In general, cervical metastasis is seen in less than 8% of patients at the time of presentation. The excision of the tumor was followed by a regional therapeutic lymph nodes dissection in the cases in which the lymph nodes involvement was clinically evident. In our series, we performed 10 therapeutic radical neck dissections on patients with clinically evident lymph nodes involvement. One of these patients died after multiple distant metastases. Postoperative radiotherapy was administered to these patients. According to Khurana et al.9 postoperative radiotherapy is not associated with improved disease control. We believe that complete surgical resection is the treatment of choice for lip skin cancers. Failure to excise the tumor is the main cause of local recurrence. The use of the Moh’s micrographic surgery for excision of lip tumors has been suggested by many authors as the method of choice.10,11 This technique was first described by Dr. Frederic Mohs in 194112 and was based on the principle that when zinc chloride was applied to tissue, the tissue was fixed and the tumor could be shaved off horizontally, after which 100% of the resection margins could be examined microscopically. Moh’s is used for large skin cancers, recurrent skin cancers, skin cancer in difficult locations (such as lips, pennies, lower eyelid, nose, fingers, etc.), and very poorly defined skin cancers. Even though Moh’s micrographic surgery provides low recurrence rates, recurrences still can occur after treatment with Moh’s technique, where theoretically 100% of the resection margins are viewed.13–17
Lip defects due to tumor excision Eliezri et al., and Dzubow both report cases where the scar tissue (in case of biopsy scar or a recurrent BCC) is not completely excised and therefore tumor is missed.13,14 Moreover, skin carcinomas may sometimes recrudesce, independently of the clear limits of the lesion. We prefer to remove completely the tumor en block with a safety margin of adjacent normal tissue in all directions, minimizing the probability of recurrence. Since 2000, we have used sentinel lymph node (SLN) biopsy in cases of cutaneous melanoma of the lips. After 2004 we have used SLN biopsy in cases of neglected SCCs of the lips (diameter P 2 cm). The technique of intraoperative lymphatic mapping and selective lymphadenectomy was introduced for melanoma patients by Morton et al.18 Because of the successful results with melanoma, investigators tried to incorporate the technique into the treatment of several other solid skin tumors such as SSCs. The risk of regional lymph node metastases is 4% for T1 lesions and 20% for T2 or greater lesions. Because of the relatively low incidence of nodal metastasis in T1 lesions, primary excision of the tumor with adequate margins is often sufficient for cure. We prefer the SLN biopsy especially to the youngest patients with central tumor location, from an unnecessary lymph node dissection of the area. The ability of sentinel lymphadenectomy to identify regionally metastatic cutaneous SCC remains to be further clarified.19 After tumor resection, the aims of reconstruction must be to maintain oral competence, maximum oral aperture, mobility, sensation when possible, and maximize aesthetic result. The restoration of a natural appearance should not be the only mainstay of reconstruction; adequate lip function is of equal importance. When defects involve more than one lip, more complex reconstructive procedures are required. The lip curtain must be of adequate height, sensated and possess adequate extrinsic and intrinsic musculature. The lower vermilion is the most common site of neoplastic lesions since it is the target of solar radiation injury. Small lesions can be excised in fusiform fashion and closed primarily. Incisions should be placed in the radially oriented relaxed skin tension lines.3 When the defect is limited to less than one third of the lower vermilion, a vermilion–muscle advancement flap based on the axial labial artery may be used to resurface the area of the defect.20 When simple advancement is inadequate, a triangular musculomucosal V–Y advancement flap can be used. Kawamoto21 described a vermilion lip switch flap for correction of cases involving large defects of vermilion. A transverse, centrally based musculomucosal flap is designed on the lower lip and then is elevated and turned upward 180 and sutured into the deficient portion of the upper lip. The flap is divided at 12–14 days. In cases of extensive premalignant lesions of the lip vermilioectomy is indicated. In this operation the vermilion is resected from the white roll to the contact area of the upper and lower lip. Repair of the defect is done by advancement of labial mucosa, which is then redraped over the underlying orbicularis musculature. The plane of dissection is between the uninvolved mucosa and underlying musculature. This method decreases the inward retraction of the lip, which occurs with primary closure, avoiding irritation by the lower lip hairs, and producing a better contour.
209 Tongue mucosal flaps22–25 have been described for vermilion reconstruction. They are rarely preferred because they are an unpleasant experience for the patient. Reconstruction of lower lip defects is eased by the lack of a dominant central structure such as the philtrum, and the greater laxicity of soft tissues. These properties allow for better mobilization of tissues adjacent to the defect without causing obvious distortion. Defects 61/3 of the horizontal length of the lower lip may be repaired with direct closure in three layers: mucosa, muscle, and skin. The patient’s age, elasticity, and redundancy of adjacent soft tissue determine the size of the defect that can be closed directly. In our series, we used the rhomboid-shaped transposition flap of Dufourmentel26 for cutaneous small defects of the upper or lower lip. The flap is located next to the primary defect in a way that facilitates direct closure of the donor site. Four flaps are mainly used for repair of defects with length between 1/3 and 2/3 of the horizontal length of the lower lip (medium defects). These are the Abbe flap, the Karapandzic flap, the Bernard–Burow’s procedure and the Estlander flap. The Abbe flap27 (Fig. 4) can be used for medium defects which do not involve the commissure and in cases where there is sufficient lower lip tissue for reconstruction. The flap is designed at the junction of the middle and lateral thirds of the upper lip so that neither the philtrum nor the commissure is affected. Then the flap is elevated and rotated along the vascular pedicle so as to fill the defect. The main potential disadvantages of this procedure are: (1) the total flap loss either intraoperatively or postoperatively, (2) the fact that it is a two stage reconstruction because the pedicle of the flap is divided after 14–21 days and the patient remains for this period of time with his lips apposed. The aesthetic result is generally better than that seen with the Bernard–Burow’s procedure and the Karapandzic flap. The Karapandzic flap28 is mainly used for medium lower lip defects that do not require new lip tissue for reconstruction and that are either located centrally or more laterally where they involve a portion of the commissure. The incision is carried circumorally to the alar base bilaterally. The incision is made in full thickness through skin, muscle, and mucosa medially. Laterally, at the level of the commissures the skin is incised only down to subcutaneous tissue. The flaps are rotated inward to fill the defect. The oral sphincter remains intact and functional after this procedure. The main potential disadvantages of this procedure are: (1) unsightly scarring, (2) the potential for microstomia which can be particularly troublesome to patients who use dentures. The Bernard–Burow’s procedure is used for reconstruction of the lower lip in cases where there is not adequate lip soft tissue after tumor excision. In the original operation, full-thickness triangles of cheek tissue are excised on each side of the upper lip, providing relief room for the lower cheek flaps to be advanced medially. This original operation has undergone multiple modifications which aim at improving the functional and aesthetic result. Main potential disadvantages of this procedure are: (1) incomplete recovery of sensation and mobility in the lip tissue, (2) scar contracture at the commissure causing an unusual ‘smiley
210
O. Papadopoulos et al.
Figure 4 (a) Squamous cell carcinoma of the lower lip. (b) Abbe flap and its pedicle. (c) Final result. (d) Natural appearance of the lower lip.
face’, (3) color mismatch of the reconstructed vermilion with adjacent vermilion, (4) drooling. Through modifications by Freeman29 and Webster et al.30 skin and subcutaneous tissue are excised in a more lateral position placing the scar in the nasolabial fold and resulting in improved postoperative sensation of the reconstructed lip. The Estlander flap is used for reconstructions of defects that involve the commissure and is impossible to be repaired by the Karapandzic flap. It is a laterally based lip switch flap, pivoting around the corner of the mouth. The flap is designed on the upper lateral lip at a size equivalent to one half of the lower lip defect. This is a one step procedure and it has the same potential disadvantages like Abbe procedure with one main exception, the rounded appearance with poor angle definition of the commissure. Reconstruction of defects P2/3 of the horizontal length of the lower lip (large defects) is a challenging problem. A reasonable degree of oral function and competence are the mainstays in this type of reconstruction. When there is sufficient remaining lip or cheek tissue the Bernard’s procedure is the method of choice for reconstruction of large lower lip defects. Another choice is the Karapandzic flap which is used for repair of medially located large lower lip defects. In massive lip defects free tissue transfer or a distant pedi-
cle flap provides the most consistent results. We prefer the use of the pedicled musculocutaneous flap of platysma for filling such defects. In cases where the defect involves the mandible, an osteomusculocutaneous flap (either free or pedicled) should be used for reconstruction. We use the pedicled musculocutaneous flap of pectoralis major muscle combined with the 4th rib for reconstruction of this type of defects (Fig. 5). Upper lip defects due to tumor excision are less common than lower ones. Reconstruction of upper lip defects is more difficult due to the presence of central structures-like nose, columella. Regional and distant flaps for repair of upper lip defects may provide more acceptable functional and aesthetic results than comparable procedures for the lower lip. Reconstruction of small upper lip defects (61/3 of the horizontal length of the lip) depends on the location of the defect. When the defect involves only the upper lip tissue, with intact vermilion, a nasolabial flap from the ipsilateral side can be used for repair of the defect. The flap (skin and subcutaneous tissue) is either superiorly or inferiorly based and is rotated into place from a position adjacent to the defect. The donor side is closed primarily along the nasolabial fold. Laterally located defects can be closed with primary closure. Medially located defects can be closed with
Lip defects due to tumor excision
211
Figure 5 (a) Squamous cell carcinoma of the lower lip involving the mandible. (b) Resection of the tumor and part of the mandible. (c) Pedicled musculocutaneous flap of pectoralis major muscle combined with the fourth rib for reconstruction of the defect. (d) Final result.
direct closure after perialar crescentic skin excisions and release of upper buccal sulcus to allow medial advancement of the lip tissue. The excision involves skin and subcutaneous tissue. Location of the defect is the main criterion for the type of reconstruction of medium defects of the upper lip (>1/3 and 62/3 of the horizontal length of the lip). Centrally located defects can be closed after perialar crescentic excisions either with primary closure if the defect is <1/2 of the horizontal length of the upper lip or with the use of
Figure 6
an Abbe flap or a Karapandzic flap for defects >1/2 of the horizontal length of the upper lip. We believe that for these defects the use of an Abbe flap is the best choice for reconstruction due to better functional and aesthetic results. Laterally positioned medium defects must be considered in the context of presence or absence of commissure involvement. When the commissure is not involved an Abbe flap can be used for repair of the defect. An Estlander flap can be used for filling of the defect when there is involvement of the commissure. If the defect involves the philtrum, the combi-
Five-year recurrence rate according to type of surgical treatment.
212 nation of a controlateral perialar crescentic excision with the use of an Estlander flap is the method of choice for repair of the defect. Repairing of large upper lip defects (>2/3 of the horizontal length of the lip) depends on the adequacy or not of the adjacent cheek tissues. When there are adequate adjacent cheek tissues for reconstruction the method of choice is the Bernard–Burow’s procedure. The upper lip is replaced with midcheek tissue. Burow’s triangles are excised laterally to the lower lip, on both sides, and laterally to each alar base. The triangular excisions involve only skin and subcutaneous tissue. The cheek tissue is then advanced medially to create the new upper lip. Vermilion reconstruction is undertaken using mucosa from the advanced cheek flaps. Laterally located large upper lip defects can be repaired with the combination of a unilateral upper lip Bernard–Burow’s procedure and a controlateral perialar crescentic excision. When there is inadequate adjacent cheek tissue for reconstruction free tissue transfer or a distant pedicle flap can be used for filling the defect. A successful reconstruction should derive from careful preoperative planning, knowledge of the anatomy, and use of sound surgical techniques. Flawless operative technique is important for a successful outcome. The use of prophylactic perioperative antibiotics is imperative. Gentle handling of tissues, meticulous hemostasis, and judicious placement of drains are of paramount importance. Careful postoperative wound inspection is necessary, for the early detection of septic complications or wound healing impairment. In our series, from the 550 patients who had a five-year follow-up we observed 62 recurrences of the primary tumor. The five-year recurrence rate was 11.28%. According to type of surgical treatment, surgical excision followed by direct closure was the type of surgery with the highest five-year recurrence rate (10.82%), even though the histological diagnosis was negative for positive margins in the majority of cases (Fig. 6). We believe that these findings were due to limited margin of adjacent normal tissue and the low grade of differentiation of these tumors. Ancillary studies are needed to confirm our findings. In conclusion, we suggest that postoperatively, patients should have systemic annual follow-ups. Individual risk assessment should be routine, and those at a particular high risk, such as those with previous skin tumors, require more intensive monitoring. It is essential for the plastic and reconstructive surgeon to be familiar with the particular procedures used in eyelid reconstruction. He should have close cooperation with the patient to succeed in performing a suitable outcome.
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