- Email: [email protected]
Total vermilionectomy; indications and technique
EuropeanJournalof SurgicalOncology 1995; 21:201-203
Total vermilionectomy; indications and technique Sldlka Kurul, Adnan Uzunismail* and Ahmet Kizirt Departments of Surgical Oncology and t Radiation Oncology, Institute of Oncology, Istanbul University, and *Department of Plastic and Reconstructive Surgery, Haydarpasa Teaching Hospital Galhane Military Medical Academy and Medical School lstanbul
In this study, total vermilionectomy, indications and technique are discussed. The results of 33 cases are presented with review of the literature.
Key words: Hp cancer; 'vermilionectomy'; lip shave; mueosal flap.
Introduction
Material and methods
For a number of years, leukoplakia, keratosis and diffuse dysplastic mucosal changes have been reported as precancerous lesions of the lip. These white patchs or superficial ulcerated lesions on the vermilion mucosa develop as a result of chronic irritation. ~.2 Although the exact cause of lip cancer is not known, there is ample evidence to suggest that they result from repeated damage to the mucosa, often in association with the chronic use of tobacco, vitamin deficiency, chronic exposure to solar radiation and poor oral hygiene. In the underdeveloped countries, most of the population consists of farmers. People who live outdoors during most of their daytime are subject to several predisposing conditions such as exposure to solar radiation, smoking, and poor oral hygiene. Lip cancer incidence is high in these countries) '4 There are patients with chronic changes in their lower lip mucosa in multiple sites which could progress to squamous cell cancer. Therefore, although leukoplakias may be treated by a conservative method and observation, if they persist, they should be biopsied and treated surgically. Prevention and treatment of precancerous lesions are essential to reduce the incidence of lip cancer.~-4 Ideal treatment involves complete surgical excision of the affected mucosa of the lip. Vermilionectomy is widely accepted as a prophylactic operation for the removal of diffuse dysplastic changes of the lip. Vermilionectomy can be combined with wedge resection of the tumour and a variable amount of orbicularis oris muscle (in depth) along the lip. -''5'6 This report describes the results of 33 cases in whom total vermilionectomy and reconstruction by buccal advancement flap due to diffuse dysplastic changes was performed; indications for total vermilionectomy with review of the related literature are presented.
Thirty-three patients had lower lip involvement. The youngest patient was 36 and the oldest was a 70-year-old man. Of the 33 patients eight were female. All lesions were limited to the vermilion mucosa. Twentyfive of 33 males were farmers. The most common aetiological factors were chronic exposure to solar radiation together with smoking. Eight patients had already received radiation therapy for previous lip cancer. Symptomatic duration was 6-18 months in spite of medical treatment. All patients were operated under local anaesthesia on an outpatient basis. The vermilion was resected as clinical circumstances dictated and included the white roll and shaving of the muscle. When occult carcinoma was present, wedge resection was carried out. After completion of the resection, the buccal mucosa of the lower lip was dissected in the plane between the muscularis and the glandular layer extending deep into the gingivo-buccal sulcus. Following meticulous haemostasis, the mucosal flap was advanced to the cut end of the lower lip skin and was sutured with continuous 5/0 Vicryi. This procedure was combined with wedge resection in eight patients with a small lip carcinoma.
Address for correspondence: Sldlka Kurul, M.D., Poyracik Sokak 37/5, Ni~anta~l 80200, Istanbul, Turkey. 0748-7983/95/020201 +03 $08.00/0
Results There was no difficulty with performing the operation under local anaesthesia. All patients tolerated the procedure well. The patients left the hospital and began eating and drinking on the same day. Application of cold cream (Furacin ®) for a week was advised to prevent dryness and scaling of the new vermilion. All wounds healed uneventfully, in spite of eight of 33 patients having received previous radiation therapy. The histologic examination (Table 1) revealed leukoplakia-- keratosis (10), chronic inflammation (2), squamous cell carcinoma (superficially invasive in five), leukoplakia and squamous cell carcinoma (8) and radiation injury (8). In the follow-up period, the lower lip profile was natural © 1995 W.B. SaundcrsCompany Limited
S. Kurul et al.
202 Table 1. Histology of vermilionectomy Histologic feature
No. of cases
Leukoplakia--keratosis Leukoplakia and squamous cell carcinoma Radiation injury Squamous cell carcinoma (superficiallyinvasive) Chronic inflammation
10
Total
33
8 8
(AI and the vermilion ridge stood out well in all but one patient (Figs IA,B, 2A,B). Sensation was present after a week following the operation. Lip functions such as drinking, blowing, whistling, etc. recovered within a few days. There was no recurrence of lip lesions in 24 months of follow-up period. Discussion
Vermilionectomy is a very simple and safe operation to resolve non-malignant lesions of the lip. When mucosal changes involve multiple sites of the vermilion, this procedure provides the pathologist with a large specimen for detailed examination whether the lesion is malignant or not. All the specimens excised during the vermilionectomy should be marked in position to give more information to the pathologist, and if there is any suspicion of a malignant condition, the deep margin of the specimen should clearly illustrate a tumour-free condition.
(AI
T~"
~'j
(BI Fig. 1. A 55-year-old man with diffuse superficial ulceration of the lower lip. (A) Preoperative appearance. (B) Total vermilionectomy and reconstruction with mucosal advancement flap were performed. Appearance at 6 months postoperatively.
(B) Fig. 2. A 35-year-oldman, a farmer, with diffuse superficialchanges of the mucosa and squamous cell carcinoma. (A) Preoperative view. Total vermilionectomy together with wedge resection were carried out and the defect reconstructed by simple mucosal advancement flap. (B) Postoperative result. This case was the only one with unsatisfactory results.
The vermilionectomy procedure permits combination with wedge resection if T~ squamous cell carcinoma is present and a variable resection of muscle in depth of the vermilion if there is ulceration or superficially invasive squamous cell carcinoma. There are different methods of resurfacing the lower lip after total vermilionectomy. A simple mucosal advancement flap from the inferior labial sulcus is a useful technique for reconstruction of a total vermilionectomy defect of the lower lip ~2'5'6. Rayner and Arscott 7 criticized this technique as it might result in thin lip with dysfunction related to the need to stretch the mucosa against and over the pliable soft tissue of the lip, and also claimed that prolonged lip numbness and secondary trauma would be common. They described a new technique which can be tailored to give bulk to the lower lip and can be combined with more extensive lip resection. In this technique, the vermilion defect was reconstructed by bilateral cheek musculo-mucosal flaps in 12 cases with acceptable appearance. Kolhe and Leonard ~ suggested that the simple mucosal advancement flap technique caused inversion of the lower lip, irritation of the upper lip and tongue, and an unnatural appearance of the lower lip. The authors described another new technique of orbicularis otis myo-mucosal flap with V-Y plasty fashion. The results for patients who underwent myo-mucosal flap procedure were satisfactory. However, in the irradiated lip, this technique could provide an insufficient blood supply.
Total vermilionectomy
In spite of these criticisms, we have not observed a noticeably thinner lower lip in the postoperative period or dysfunction. As mentioned above, sensation returned in a few days. On the other hand, the simple mucosal advancement flap technique can always be performed under local anaesthesia, so that the operative time can be short and the cost of this procedure is very low. Recovery takes a short time and the rate of complications is rare. This procedure can also be performed on the irradiated lip. However, if the lesion involves the mucosa at the commissure or if more than half of the orbicularis oris muscle has been resected, another technique, may be necessary which can improve lip fullness. In conclusion, the buccal mucosal advancement flap procedure provides a useful cosmetic and functional reconstruction of the lower lip following vermilionectomy even in irradiated cases.
2.
3. 4. 5. 6. 7. 8.
Cancer of the Head and Neck (2nd edition). Edinburgh: Churchill Livingstone, 1989:383-415. Gaisford JC, Hanna DC. Oromandibular tumors: Reconstructive aspects. In: Converse JM (Ed.). Reconstructive Plastic Surgery (2nd edition). Philadelphia: W.B. Saunders Co., 1971: 2589-2641. Chen J, Katz RV, Krutchkoff DJ, Eisenberg E. Lip cancer incidence trends in Connecticut, 1935-1985. Cancer 1992; 70: 202530. Fincham SM, Hanson J, Berkel J. Patterns and risks of cancer in farmers in Alberta. Cancer 1992; 69: 127"6-85. Zide BM. Deformities of the lips and cheeks. In: McCarthy JG (Ed.). Plastic Surgery (3rd edition). Philadelphia: W.B. Saunders Co., 1990: 2009-56. Field LM. An improved design for vermilionectomy with a mucous-membrane advancement flap. J Dermatol Surg Oncol 1991; 17:633-4 Rayner CR, Arscott GD. A new method of resurfacing the"lip. Br J Plast Surg 1987; 40: 454-8. Kolhe PS, Leonard AG. Reconstruction of the vermilion after 'lip-shave'. 1988;41: 68-73.
References
1. Baker SR. Cancer of the lip. In: Myers EN, Suen SY (Eds).
203
A cceptedfor publication 17 November 1994
Total vermilionectomy; indications and technique Sldlka Kurul, Adnan Uzunismail* and Ahmet Kizirt Departments of Surgical Oncology and t Radiation Oncology, Institute of Oncology, Istanbul University, and *Department of Plastic and Reconstructive Surgery, Haydarpasa Teaching Hospital Galhane Military Medical Academy and Medical School lstanbul
In this study, total vermilionectomy, indications and technique are discussed. The results of 33 cases are presented with review of the literature.
Key words: Hp cancer; 'vermilionectomy'; lip shave; mueosal flap.
Introduction
Material and methods
For a number of years, leukoplakia, keratosis and diffuse dysplastic mucosal changes have been reported as precancerous lesions of the lip. These white patchs or superficial ulcerated lesions on the vermilion mucosa develop as a result of chronic irritation. ~.2 Although the exact cause of lip cancer is not known, there is ample evidence to suggest that they result from repeated damage to the mucosa, often in association with the chronic use of tobacco, vitamin deficiency, chronic exposure to solar radiation and poor oral hygiene. In the underdeveloped countries, most of the population consists of farmers. People who live outdoors during most of their daytime are subject to several predisposing conditions such as exposure to solar radiation, smoking, and poor oral hygiene. Lip cancer incidence is high in these countries) '4 There are patients with chronic changes in their lower lip mucosa in multiple sites which could progress to squamous cell cancer. Therefore, although leukoplakias may be treated by a conservative method and observation, if they persist, they should be biopsied and treated surgically. Prevention and treatment of precancerous lesions are essential to reduce the incidence of lip cancer.~-4 Ideal treatment involves complete surgical excision of the affected mucosa of the lip. Vermilionectomy is widely accepted as a prophylactic operation for the removal of diffuse dysplastic changes of the lip. Vermilionectomy can be combined with wedge resection of the tumour and a variable amount of orbicularis oris muscle (in depth) along the lip. -''5'6 This report describes the results of 33 cases in whom total vermilionectomy and reconstruction by buccal advancement flap due to diffuse dysplastic changes was performed; indications for total vermilionectomy with review of the related literature are presented.
Thirty-three patients had lower lip involvement. The youngest patient was 36 and the oldest was a 70-year-old man. Of the 33 patients eight were female. All lesions were limited to the vermilion mucosa. Twentyfive of 33 males were farmers. The most common aetiological factors were chronic exposure to solar radiation together with smoking. Eight patients had already received radiation therapy for previous lip cancer. Symptomatic duration was 6-18 months in spite of medical treatment. All patients were operated under local anaesthesia on an outpatient basis. The vermilion was resected as clinical circumstances dictated and included the white roll and shaving of the muscle. When occult carcinoma was present, wedge resection was carried out. After completion of the resection, the buccal mucosa of the lower lip was dissected in the plane between the muscularis and the glandular layer extending deep into the gingivo-buccal sulcus. Following meticulous haemostasis, the mucosal flap was advanced to the cut end of the lower lip skin and was sutured with continuous 5/0 Vicryi. This procedure was combined with wedge resection in eight patients with a small lip carcinoma.
Address for correspondence: Sldlka Kurul, M.D., Poyracik Sokak 37/5, Ni~anta~l 80200, Istanbul, Turkey. 0748-7983/95/020201 +03 $08.00/0
Results There was no difficulty with performing the operation under local anaesthesia. All patients tolerated the procedure well. The patients left the hospital and began eating and drinking on the same day. Application of cold cream (Furacin ®) for a week was advised to prevent dryness and scaling of the new vermilion. All wounds healed uneventfully, in spite of eight of 33 patients having received previous radiation therapy. The histologic examination (Table 1) revealed leukoplakia-- keratosis (10), chronic inflammation (2), squamous cell carcinoma (superficially invasive in five), leukoplakia and squamous cell carcinoma (8) and radiation injury (8). In the follow-up period, the lower lip profile was natural © 1995 W.B. SaundcrsCompany Limited
S. Kurul et al.
202 Table 1. Histology of vermilionectomy Histologic feature
No. of cases
Leukoplakia--keratosis Leukoplakia and squamous cell carcinoma Radiation injury Squamous cell carcinoma (superficiallyinvasive) Chronic inflammation
10
Total
33
8 8
(AI and the vermilion ridge stood out well in all but one patient (Figs IA,B, 2A,B). Sensation was present after a week following the operation. Lip functions such as drinking, blowing, whistling, etc. recovered within a few days. There was no recurrence of lip lesions in 24 months of follow-up period. Discussion
Vermilionectomy is a very simple and safe operation to resolve non-malignant lesions of the lip. When mucosal changes involve multiple sites of the vermilion, this procedure provides the pathologist with a large specimen for detailed examination whether the lesion is malignant or not. All the specimens excised during the vermilionectomy should be marked in position to give more information to the pathologist, and if there is any suspicion of a malignant condition, the deep margin of the specimen should clearly illustrate a tumour-free condition.
(AI
T~"
~'j
(BI Fig. 1. A 55-year-old man with diffuse superficial ulceration of the lower lip. (A) Preoperative appearance. (B) Total vermilionectomy and reconstruction with mucosal advancement flap were performed. Appearance at 6 months postoperatively.
(B) Fig. 2. A 35-year-oldman, a farmer, with diffuse superficialchanges of the mucosa and squamous cell carcinoma. (A) Preoperative view. Total vermilionectomy together with wedge resection were carried out and the defect reconstructed by simple mucosal advancement flap. (B) Postoperative result. This case was the only one with unsatisfactory results.
The vermilionectomy procedure permits combination with wedge resection if T~ squamous cell carcinoma is present and a variable resection of muscle in depth of the vermilion if there is ulceration or superficially invasive squamous cell carcinoma. There are different methods of resurfacing the lower lip after total vermilionectomy. A simple mucosal advancement flap from the inferior labial sulcus is a useful technique for reconstruction of a total vermilionectomy defect of the lower lip ~2'5'6. Rayner and Arscott 7 criticized this technique as it might result in thin lip with dysfunction related to the need to stretch the mucosa against and over the pliable soft tissue of the lip, and also claimed that prolonged lip numbness and secondary trauma would be common. They described a new technique which can be tailored to give bulk to the lower lip and can be combined with more extensive lip resection. In this technique, the vermilion defect was reconstructed by bilateral cheek musculo-mucosal flaps in 12 cases with acceptable appearance. Kolhe and Leonard ~ suggested that the simple mucosal advancement flap technique caused inversion of the lower lip, irritation of the upper lip and tongue, and an unnatural appearance of the lower lip. The authors described another new technique of orbicularis otis myo-mucosal flap with V-Y plasty fashion. The results for patients who underwent myo-mucosal flap procedure were satisfactory. However, in the irradiated lip, this technique could provide an insufficient blood supply.
Total vermilionectomy
In spite of these criticisms, we have not observed a noticeably thinner lower lip in the postoperative period or dysfunction. As mentioned above, sensation returned in a few days. On the other hand, the simple mucosal advancement flap technique can always be performed under local anaesthesia, so that the operative time can be short and the cost of this procedure is very low. Recovery takes a short time and the rate of complications is rare. This procedure can also be performed on the irradiated lip. However, if the lesion involves the mucosa at the commissure or if more than half of the orbicularis oris muscle has been resected, another technique, may be necessary which can improve lip fullness. In conclusion, the buccal mucosal advancement flap procedure provides a useful cosmetic and functional reconstruction of the lower lip following vermilionectomy even in irradiated cases.
2.
3. 4. 5. 6. 7. 8.
Cancer of the Head and Neck (2nd edition). Edinburgh: Churchill Livingstone, 1989:383-415. Gaisford JC, Hanna DC. Oromandibular tumors: Reconstructive aspects. In: Converse JM (Ed.). Reconstructive Plastic Surgery (2nd edition). Philadelphia: W.B. Saunders Co., 1971: 2589-2641. Chen J, Katz RV, Krutchkoff DJ, Eisenberg E. Lip cancer incidence trends in Connecticut, 1935-1985. Cancer 1992; 70: 202530. Fincham SM, Hanson J, Berkel J. Patterns and risks of cancer in farmers in Alberta. Cancer 1992; 69: 127"6-85. Zide BM. Deformities of the lips and cheeks. In: McCarthy JG (Ed.). Plastic Surgery (3rd edition). Philadelphia: W.B. Saunders Co., 1990: 2009-56. Field LM. An improved design for vermilionectomy with a mucous-membrane advancement flap. J Dermatol Surg Oncol 1991; 17:633-4 Rayner CR, Arscott GD. A new method of resurfacing the"lip. Br J Plast Surg 1987; 40: 454-8. Kolhe PS, Leonard AG. Reconstruction of the vermilion after 'lip-shave'. 1988;41: 68-73.
References
1. Baker SR. Cancer of the lip. In: Myers EN, Suen SY (Eds).
203
A cceptedfor publication 17 November 1994