Nasolabial flap reconstruction for carcinoma of the lower lip

Nasolabial Flap Reconstruction Carcinoma

of the Lower Lip

An Eleven Year Follow-Up ANDREW

W. WALKER,

for

Study

M.D., St. Louis, Missouri, AND JOHN E. SCHEWE,

JR., M.D.,

Columbia, Missouri

From the Department of Surgery, the Ellis Fischel State Cancer Hospital, Columbia, Missouri. This work was supported in part by a Senior Clinical Traineeship from the Cancer Control Program (Dr. Walker), U.S.P.H.S. Grant No. CST 311-65.

mainder excision flap.

Thirty-seven of the patients Race, Sex, and Age. were white men whereas only two were white women. The ages of the thirty-nine patients who had reconstruction with a nasolabial flap were as follows: from thirty to thirty-nine, one; from forty through forty-nine, one; from fifty through fifty-nine, three; from sixty through sixty-nine, six; from seventy through seventy-nine, sixteen; from eighty through eighty-nine, twelve. Thus, the majority of patients were in their eighth and ninth decades. The age range was from thirty-eight to eighty-nine years, The average duration of symptoms was Duration. thirty-three months, with a range of from one to one hundred fifty-six months. This included those patients who had been treated previously and in whom recurrence had developed. In those patients in whom there was no previous treatment, the average duration of symptoms was sixteen months. Size. Although the size of the tumors ranged from 1.3 to 6.0 cm., the average tumor size was 3 cm. The left part of the lower lip was involved with tumor in twenty patients, whereas the right part of the lower lip was the site of involvement in fifteen patients. Four patients had tumors located in the central portion of the lower lip. Perras [2] stated that lesions of the left part of the lower lip have a poorer prognosis than lesions on the right or the central portion. He also stated that distant metastasis comes about easier due to the left-sided thoracic duct. In our series the right and left parts of the lip were involved almost equally in the fatal cases. Fifty-six per cent of the thirty-nine Trecttment. patients had had no prior treatment before excision of the tumor and reconstruction of the defect by the nasolabial flap. The average size of the tumors in these patients was 3.25 cm.

for reconstruction of the lower of large tumors facilitated the development of the nasolabial flap when the size of the defect was too great to permit primary closure without deformity. The procedure consists of developing a full thickness flap of cheek and upper lip, including skin and buccal mucosa, from the nasolabial fold on the side of the defect, and rotating this flap into the defect of the lower lip. This single stage reconstruction of the lower lip is highly satisfactory from the cosmetic as well as the functional standpoint. Neither long-term hospitalization nor general anesthesia is needed ; the procedure can be carried out adequately using local anesthesia

T lip after excision HE

NEED

PI.

The purpose of this paper is to determine whether the recurrence rate of tumors after reconstruction with the nasolabial flap exceeded that of other forms of treatment or was an acceptable form of treatment. CLINICAL MATERIAL Between 1955 and 1965 five hundred and fiftyfive patients were treated for carcinoma of the lip at the Ellis Fischel State Cancer Hospital. The majority of patients were treated by a V type lip excision or radiotherapy. Generally these patients had small tumors, less than 1.5 cm. in diameter. Ten other patients had reconstruction with an Estlander flap, forehead flap, or chest flap. The reVol. 113. June

1967

(thirty-nine patients) were treated by and reconstruction with the nasolabial

783

784

Walker

and Schewe

TABLE I PATHOLOGIC GRADING OF SQUAMOUS CELL CARCINOMA OF

with

persistent

LOWER LIP

In 57 per recurrence

---Grade

I---

Verrucous

Grade

Total

Grade III

I1

4 1 5

12 3 15

15 5 20

whereas after

with

grade

and

two

It

per

cent

is interesting

been

to

treated

patients Perez

by

the

et al

be treated

note

Pathology.

The

III tumors

tumors

eight either

flap

all

study.

of metastasis

to reconstruction

with with

a 14 per cent

are

Only

no previous

the nasolabial

local

per cent had regional

persistent

survival only

cancer

cancers an

Ward

area.

year

Of

rate

is 56

10 per cent

or recurrent

were

cancer

survival

of

patients

of the face

rate

is

had

a

or neck

in whom

45 per

skin

were basal or except

carcinoma

patients

developed,

in

the

recurrence

cent

had

a second

that

the three

tumor.

and Hendrick cure rate

all

all of which

epidermoid

all

malignant

in diameter

all

cent

was

which

five

classified

per

carcinoma,

skin

as

[4]

noted

for carcinoma

of the lower

greater

than

and 3 cm.

lip was 49 and 41 per cent,

respectively. COMMENTS

twenty-

or metastasis, Those noted

who

It

did

in Tables

recurrence

lymph

node

one patient

treatment flap, rate.

Another

metastasis

of

results,

was

Small

14 of

cancer

except

of

lesions

that

the

lip,

produce in those

who

surgical

normal

died

observed

excision

carcinoma,

but no

in this group

been

surgical

prior

there

has

control

TABLE

Patient

III

of the tumor

with

roughly

patients

are better easiest

excision

with

on

each

with

Tumor Grade

(cm.)

Site of Recurrence or Metastasis

Recurrence after Initial Treatment

surgery.

by

lb cm.

side.

verrucous

by

to treat a

Wide

a

12 6

1

3

II

Neck

5

II

Neck

3 4

4 4

III

5

4

III

Neck Lip and mandible Lip

19

6

2.5

II

Lip

14

I

4 8

V type

margin

of

superficial

II

Recurrent Type

Secondary

of

Treatment

PersLrtent Tumors

Other Primary Tumors

CASES)

Follow-Up Study after Secondary Treatment (mo.)

(mo.)

2

and

equivalent

treated

are

tissue

in terms of local radiotherapy

RECURRENCES AFTER NASOLABIAL FLAP RECONSTRUCTION WITH NO PRIOR TREATMENT (SIX

Size of Original Tumor

of a grade

accumulative

epidermoid

primary

III.

In those patients

recurrence.

10 year

one

or metastasis

the

of

died

accumulative

persistent

primary

graded

classified

reconstruction,

had no recurrence

or follow-up

recurrences

II and

The

by

cent

carci-

of the four patients

had recurrences patients

IV.) However,

Twenty-three

in the classifi-

75 per

Three

One

verrucous

recurred.

have

at death

have

whereas

nasolabial

patients

were

tumor

per cent of the tumors

II recurred,

the

were

patients)

year

(Table

to have

second

carcinoma.

of tumors (twenty

I.) Four

Twenty-five

grade

local

II

these

local there

or radiotherapy. local

had regression

III tumors

five

tonsillar

or

surgery

persistent

another

secondary

24 per cent.

these

should

with

flap reconstruction,

radiotherapy. of

at death.

had

of

such tumors

majority

(Table

I or

After

three

verrucous

that

been

patients

In

a

had

or radiotherapy.

twelve

III, the least differentiated

grade

only

that

was

believe

patients)

pathologist. cation.

patients

by surgery.

I (fifteen grade

the

surgery

radiotherapy.

tumor

[3]

of

by either

this was a grade

disease.

known previously

patients

of initial

The

Forty-four

of

with

died

per cent.

treated

tumor;

nasolabial

patient noma

1 3 4

cent

after

was a history

tumor No recurrence Recurrence Total

or recurrent

III tumor.

Radical neck dissection Radical neck dissection and radiotherapy Radical neck dissection Jaw, neck, and lip dissection Excision and radiotherapy Excision

112 28

No Yes

Skin Skin

NO

NO

None Skin

87* 7

Yes

None

19

No

Skin

84

* Patient still alive. American

Journal

of Surge?‘Y

Reconstruction

for Carcinoma TABLE

SECONDARY

RECURRENCE

AFTER

NASOLABIAL

FLAP

Patient

Site of Recurrence or Metastasis

Tumor Grade

Recurrence after Nasolabial Flap

III

RECONSTRUCTION (FIVE

Size of Tumor (cm.)

of Lower Lip

AFTER

INITIAL

SURGERY

OR

RADIOTIIERAI’1

CASES)

Recurrent or Persistent Tumors

Type of Secondary Treatment

s~~c~!~n

Other Tumors

Follow-ITp Study after Secondary Treatment imr,. 1

(mo.1 1

1

3

1.6

II

:s

1.3

I

4

2. 0

II

5

2

5

Mandible Mandible and neck Mandible Xeck Lipt and neckt

III

5

I

30 5

Radiotherapy Jaw and neck dissection

Regression NO

None Skin

4 4x*

1 16 18

Jaw and neck dissection Neck dissection Radiotherapy and surgery

No No Persistent

None None None

3 19* 36

* Patient still alive. t \‘errucous carcinoma

for the reconstruction of large defects of the lower lip after excision of tumors. Radiotherapy can effectively control these advanced neoplasms but often results in a loss of lip substance with a poor cosmetic result and frequently there is incontinence of the oral stoma.

tumors can be treated by radiotherapy with excellent cosmetic results and functioning oral stoma. In advanced lesions, however, in which the tumor has already destroyed normal lip substance, construction of a new lip is essential to provide a functioning lip. In the past it has not been possible to carry out this reconstruction at the time of the treatment of the primary lesion. The nasolabial flap provides the means

SUMMARY

Although the number of cases of cancer of the

TABLE SURVIVAL

RATE

OF PATIENTS

TREATED

FOR CARCINOMA

Time after Nasolabial Flap Reconstruction (yr.) o-1 l-2 Z-3 3-4 4-5 Fi-6 6-i 7-H 8-9 9-10 lo-1 1

. N”‘a~‘ve Beginning of Interval

39 33 27 20 15 11 9 6 6 2 1

No. Dying in Interval

No. Lost to Follow-Up Study during Interval

3 4 3 1 2 2 1 0 2 0 1

0 0 0 0 0 0 0 0 0 0 0

IV

WITH OF THE

Withdrawn Alive from Follow-Up Study during Interval 3 2 4 4

2 0 2 0

2 1 0

NASOLABIAL LOWER

LIP

FLAP

Effective No. at Risk*

37.5 32 25 18 14 11 8 6 5 1 .5 1

RECONSTRUCTION

[;]

---Proportion-Alive Dyingt

0.08 0.13 0.12 0.06 0.15 0.18 0.13 0.00 0.40 0.00 1.00

0.92 0.87 0.88 0.94 0.85 0.82 0.87 1.00 0.60 1.00 0.00

Accumulative Survival Rate:

0.92 0.80 0.70 0.66 0.56 0.46 0 .40

0.40 0.25 0.24 0.00

* The number living at the beginning of the interval minus one half the number lost and withdrawn alive from the study during the interval. t Division of the number dead by the effective number at risk for the interval. $ Determined by multiplying the product of the proportions living to each of the preceding intervals by 100. Vol.

113*

June 1967

$86

Walker

lip posing a problem in reconstruction will be small, the use of the nasolabial flap is a useful adjunct to the armamentarium. As stated in a previous article [I], the following advantages of this procedure are noted: (1) It is a single stage procedure which can be conducted under local or block anesthesia. (2) Hospitalization is brief and convalescence is uncomplicated with oral intake possible on the day of operation. (3) Cosmetic results are satisfactory. (4) Functional results are good; continence of the oral stoma is maintained, and patients can continue using dentures; phonation is unimpaired. (5) The operative field has not overlapped into that of neck dissection, should such a procedure become necessary. Additionally, it can be noted that (6) verrucous carcinomas are best treated by surgery and (7) the recurrence rate is

and Schewe less than that with other acceptable methods of treatment for the size and type of tumor. REFERENCES 1. SCHEWE, E. J. A technique

2. 3.

4.

5.

for reconstruction of the lower lip following extensive excision for cancer. Ann. Surg., 146: 285, 1957. PERRAS, C. Carcinoma of the lip. Am. J. Surg., 104: 746, 1962. PEREZ, C. A., KRAUS, F. T., EVANS, J. C., and POWERS, W. E. Anaplastic transformation in verrucous carcinoma of the oral cavity after radiation therapy. Radiology, 86: 108, 1966. WARD, G. E. and HENDRICK, J. W. Results of treatment of carcinoma of the lip. Surgery, 27: 321, 1950. MOYER, C. A., RHOADS, J. E., ALLEN, J. G., and HARKINS, H. N. Surgery, Principles and Practice, 3rd ed., p. 1734. Philadelphia, 1965. J. P. Lippincott co.

American

Joumal

of Surgery