The lips 5

INTRODUCTION

Cancer of the l i p is a c o m m o n p r o b l e m in t h e sunbelt areas

comprising as m u c h as :i()% of all malignant tumors of the oral
cavity. In these regions, this is the most c o m m o n cancer of the
oral cavity a n d is second o n l y to skin cancer of the head a n d neck
in incidence. In general, the behavior of cancer of the lip is similar
to that of skin cancer rather t h a n carcinomas of mucosal origin
arising in the oral cavity. Nearly 9 5 % of all l i p cancers occur in
men. The lower lip is by far the most frequent site, w i t h o n l y 7%
arising in the upper l i p a n d 4% at the oral commissure (Fix- S.l).
The lower lip is at a significantly h i g h risk for exposure to sun Fig. 5.1 Site and gender distribution: squamous cell carcinoma of the
lips.
compared w i t h the upper lip and hence the discrepancy in the
distribution between upper a n d lower lips. S m o k i n g of cigars a n d
pipes is also considered an i m p o r t a n t etiologic factor. Squamous
cell carcinoma is the most p r e d o m i n a n t histological variant w i t h
melanoma and carcinoma of minor salivary gland origin
comprising the rest ( F i g . S.2). Basal cell carcinomas of cutaneous
origin sometimes e x t e n d l o t h e v e r m i l i o n b o l d e r a n d i n v o l v e t h e
lip.

ANATOMICAL CONSIDERATIONS

The upper lip is formed by the fusion of lateral m a x i l l a r y processes

and a central nasofrontal process. This e m b r y o n i c fusion leads to
the presence of a central m i d l i n e mass w i t h t w o lateral larger
segments. Because of the separation of the lateral segments,
Fig. 5.2 Histologic distribution: carcinoma of the lips
contralateral neck metastasis f r o m upper lip cancer is exceedingly-
rare. O n the o t h e r h a n d , the lower l i p i s f o r m e d b y fusion o f t w o
lateral mandibular processes in the m i d l i n e . Ibis puts lower lip dissemination of metastatic disease occurs to deep jugular lymph
cancers at increased risk of contralateral neck metastasis. Blood nodes at Level II a n d Level I I I . Metastatic dissemination to Level
supply to the lips is provided by the superior a n d inferior labial IV a n d Level V is exceedingly rare. On the other h a n d , bilateral
arteries and branches of the facial artery on each side. The labial metastasis to l e v e l I l y m p h nodes is not u n c o m m o n .
arteries form an arcade around the oral c a v i t y such that lesions in
the lateral aspect of the l i p receive b l o o d supply b o t h f r o m its
CLINICAL CHARACTERISTICS, DIAGNOSIS, AND
medial and lateral regions. Sensory s u p p l y to the skin a n d
STAGING
vermilion border of the upper and lower l i p is provided by the
maxillary and mandibular divisions of the trigeminal nerve
respectively. Muscular c o n t r o l of the orbicularis oris a n d levators The clinical presentation of cancer of the lip is quite characteristic
and depressors of the oral commissure is provided by the facial w i t h an ulcerated or e x o p h y t i c cauliflower-like lesion on the
nerve. Lymphatic drainage of the lips is well defined and follows v e r m i l i o n border w i t h varying degrees of i n f i l t r a t i o n of the
a predictable pattern for metastatic dissemination. Lesions of the u n d e r l y i n g musculature, invasion of the o v e r l y i n g skin, or labial
lateral aspect of the upper lip first drain to buccal a n d periparotid mucosa ( F i g . 5.3). The lesion m a y involve a p o r t i o n of the lower
lymph nodes as well as l y m p h nodes in the prevascular facial lip, the entire lower lip, the commissure of the oral cavity, or both
region o v e r l y i n g the body of the m a n d i b l e . Subsequent to this, the upper a n d lower lips (Figs 5 . 4 - 5 . 6 ) . M a n y well-differentiated
l y m p h node metastasis occurs at Level I in the submandibular squamous carcinomas are associated w i t h varying degrees of
triangle and then i n t o the deep jugular c h a i n . Lymphatics of the hyperkeratosis a n d leukoplakia of the v e r m i l i o n border of the lip.
lower lip i n i t i a l l y drain to l y m p h nodes at Level I in the submental These pathological changes should be considered in surgical
and submandibular region as well as to the prevascular facial treatment p l a n n i n g for resection and reconstruction of the lips.
l y m p h nodes o v e r l y i n g the b o d y of the m a n d i b l e . Subsequent The p r i m a r y lesions m a y be ulcerative, e x o p h y t i c or endophytic.
Fig. 5.3 Localized cancer of the lower lip, Fig. 5.5 Squamous carcinoma of the upper lip.

Fig. 5.4 Advanced carcinoma of the lower lip with deep infiltration of Fig. 5.6 Exophytic, cauliflower-like carcinoma of the oral commissure.
soft tissues and skin.

The staging criteria for primary cancer of the lip are similar to
those employed for tumors of the oral cavity. Tumors <2 cm are
staged as I I , 2-4 cm as 12, >4 cm as T3, and massive tumors with
invasion of the deep soli tissues, adjacent bone, or overlying skin
are staged T4. A majority of patients, however, present with early
staged tumors for diagnosis and treatment. Only 10% of patients
present with clinically palpable cervical lymph node metastasis.
The stage distribution of patients with carcinoma of the lip at
diagnosis is shown in l ; ig. 5.7.

RADIOGRAPHY

Radiographic workup of early stage tumors of the lip is usually not

indicated. However, advanced tumors of the lower lip, particularly
with adherence to, or invasion of, the adjacent mandible, require
adequate evaluation. In addition to this, neurotropic carcinomas,
particularly melanoma and squamous carcinoma, have a tendency
to disseminate along the inferior alveolar nerve through the Fig. 5.7 Stage distribution: squamous cell carcinoma of the lips.
Fig. S.8 Invasion of the mandibular canal shown on an oblique plain
x-ray of the mandible.

atrophy of the underlying musculature with indentation at the

site of the primary tumor. Larger lesions require planned surgical
resection with reconstruction, keeping in mind the esthetic-
appearance of the lips, the competency of the oral cavity, and
preservation of the nerve and blood supply to the remaining
musculature of the lips to maintain facial expression.

FACTORS AFFECTING CHOICE OF TREATMENT AND

SELECTION OF THERAPY

The factors that affect the selection of initial therapy are related to
Fig. 5.9 Panoramic x-ray of the mandible, showing invasion of the the tumor and the patient. As indicated earlier, small superficial
inferior alveolar nerve in the mandibular canal. lesions are easily manageable by expeditious simple surgical
excision with primary repair. Larger lesions require adequate pre-
operative preparation with surgical planning to include the method
mandibular canal (Fig. S.8). Therefore, detailed and careful of reconstruction most suitable to the surgical delect created and
radiographic evaluation of the mandible is vitally important in the available volume and characteristics of the tissues of the
treatment planning. Patients who manifest numbness of the skin patient. Larger lesions with invasion of the overlying skin or the
of the chin and lower lip are particularly suspect of having invasion underlying mandible require a three-dimensional resection with a
of the inferior alveolar nerve. Panoramic x-rays of the mandible plan of immediate reconstruction, most suitably using a micro-
provide a good initial assessment of the mandibular canal (Fig. vascular composite free flap. The most vital component of surgical
S.9). More detailed studies require a C I ' scan and, in select reconstruction of the lip requires restoration of the competency of
circumstances, a Dentascan for accurate delineation of the extent the oral cavity, reconstruction of the oral commissures when tech-
of bone invasion as well as for evaluation of invasion of the nically feasible to restore facial expression, and preservation or
inferior alveolar canal (Fig. 5.10). restoration of the size of the entrance to the oral cavity to preserve
the patient's ability to eat by mouth and retain well-articulated
speech. Patient-related factors include the general medical con-
TREATMENT GOALS dition of the patient in relation to the safety of anesthesia and
surgical procedure, particularly when major composite resection
with microvascular free flap reconstruction is required. Therefore,
The obvious goal of initial therapy is long-term control of cancer in selection of initial therapy, the following factors must be
with preservation of competency of the oral cavity and restoration considered:
of esthetic appearance. Small primary tumors of the lower or
upper lip can be equally well controlled by surgical excision or 1. size (T-Stage) of the primary tumor;
external or interstitial irradiation. Surgical excision for a small 2. extent of lip resection necessary;
lesion is expeditious and leaves essentially no esthetic or func- '.i. method of reconstruction;
tional debility. On the other hand, long-term impact of radio- 4. anticipated esthetic and functional result of reconstructive
therapy to the lip produces atrophy of the skin and occasional surgery;
I Fit LI K i

5. general medical condition of the patient; three-dimensional fashion (Fig. 5.131. The skin incision is placed
6. long-term impact of surgery or radiotherapy as initial with a scalpel to maintain sharp cut edges of the skin for accurate
treatment; reapproximation of the vermilion border to maintain an accep-
7. cost and convenience of treatment and compliance of the table esthetic result. The rest of the operation is completed with
patient. the use of an electrocautery to minimize blood loss. The inferior
Histology of the primary tumor is also an important consider- labial artery needs to be carefully identified during excision and
ation in initial treatment planning. While squamous carcinomas ligated. A through-and-through surgical defect is thus created
and basal cell carcinomas can be treated by external irradiation, (Fig. 5.14). Reapproximation of the surgical defect requires
melanoma, minor salivary gland carcinomas and malignant meticulous alignment of the vermilion border. A 5-0 nylon suture
tumors of soft somatic tissues are not suitable for treatment with is initially placed at the mucocutaneous junction of the vermilion
radiotherapy. border accurately aligning the vermilion edge. With traction on
this suture, 3-0 chromic catgut interrupted sutures arc taken in the
subcutaneous tissue to approximate the orbicularis oris muscle
V-EXCISION OF THE LOWER LIP
and subcutaneous soft tissues, following this, mucosal closure with
interrupted 3-0 chromic catgut sutures starting from the gingivolabial
Small superficial lesions involving the vermilion border and the sulcus up to the vermilion edge is performed. Finally, 5-0 nylon
underlying musculature of the lip are easily amenable to an interrupted sutures are taken for the skin and the vermilion
elliptical excision which can be easily performed under local border. If accurate alignment of the vermilion edge is achieved,
anesthesia with very gratifying esthetic and functional results. It is then a very pleasing esthetic result is achieved (Fig. 5.15).
important to remember that the natural skin creases on the
vermilion border are in a radial direction along the circumference
of the mouth (Fig. 5.11), excision is therefore planned
accordingly. The resulting scar virtually merges with the natural
skin lines, leaving a very pleasing esthetic result. The patient
shown in H g . S.12 has a squamous carcinoma involving the
cutaneous surface of the lower lip with deep Infiltration of the
underlying musculature extending up to the submucosal plane on
the labial aspect of the lower lip. A simple through-and-through
V-excision of the lower lip is planned to excise the lesion in a

Fig. 5.11 Natural skin creases around the mouth. Fig. 5.13 A simple V-excision is outlined.

Fig. 5.12 Squamous carcinoma of the skin involving the lower lip. Fig. 5.14 The through-and-through surgical defect.
Fig. 5.15 Primary closure w i t h accurate alignment of the vermilion
edge.
Fig. S.16 A hyperkeratotic superficially infiltrating squamous carcinoma
of the lower lip.

LIP SHAVE

The most important indications for a lip shave operation are areas
of leukoplakia with keratosis and in situ or superficially invasive
carcinomas. The entire vermilion surface of the lip may require
excision for this entity. The operative procedure is likely to be
successful if the diseased areas of the lip are confined to the
mucous membrane .surface of the lip on the vermilion border and
are not of an infiltrating nature. Small and superficial limited
regions of the vermilion mucosa can be excised by a lip shave
procedure under local anesthesia. However, extensive lip shave
procedures require general anesthetic to accomplish a satisfactory
surgical resection with appropriate reconstruction using a
bipedicled labial mucosal flap for restoration of the vermilion Fig. 5.17 The surgical defect.
border. The patient shown in Fig. 5.16 presented with a hyper-
keratotic superficial infiltrating squamous carcinoma involving
nearly 80% of the vermilion border of the lower lip. On palpation,
the lesion had essentially no infiltrative component in the under-
lying musculature. An extensive lip shave procedure with
resection of only a small amount of lip musculature is planned.
The surgical procedure is performed under general anesthesia
through a nasotracheal tube. Adequate excision of the vermilion
border is performed through an extensive lip shave procedure in a
monobloc fashion. The margins of the surgical defect must be
checked by frozen sections to ensure adequacy of resection.
The surgical defect is shown in Fig. 5.17. Mucosa of the lower
lip is now mobilized all the way up lo the attached gingivolabial
sulcus, keeping its blood supply intact through its lateral pedicles
(Fig. 5.18). Thus, the entire labial mucosa is mobilized through-
out the extent of the lower lip in a bipedicled flap fashion. A
horizontal relaxing incision is now placed in the gingivolabial
sulcus. This bipedicled mucosal flap is now advanced anteriorly
and externally to cover the surgical defect appropriately. Inter-
rupted non-absorbable sutures are used to approximate the labial
mucosa to the cutaneous margin of the surgical defect. Accurate Fig. S.18 Mobilization of the bipedicled labial mucosal flap.
alignment of the mucosa to the remaining vermilion border is vitally
important to restore the anatomic configuration of the reconstructed
lower lip (Fig. 5.19). The mucosal defect in the gingivolabial quite satisfactory primary healing of the lower lip with restoration
sulcus created by advancement of the bipedicled flap is left open of the esthetic appearance of the lower lip and preserving
to heal by secondary intention. Postoperative appearance of the the functional competency of the lower lip and the oral cavity
patient approximately three months following surgery shows (Fig. 5.20).
Fig. 5.19 Accurate alignment of the bipedicled mucosal flap to the skin Fig. 5.20 Postoperative appearance of the patient after three months.

LIP SHAVE OPERATION WITH V-EXCISION FOR lower lip following the outline as marked before. Brisk bleeding
CARCINOMA OF THE LOWER LIP from this area should be expected and therefore use of a suction
with a Frazier suction tip is preferable for a dry field. A toothed
Adson forceps is then used to grasp the tip of the surgical
The patient shown here has a nodular infiltrating squamous cell specimen on the left side, and the remainder of the dissection pro-
carcinoma of the vermilion border of the lower lip on the right- ceeds w i t h the use of fine needle t i p electrocautery with
hand side measuring approximately 1.5 cm on its surface (Fig. coagulating current (Fig. 5.23). Dissection now proceeds in a
5.211. lie also has diffuse areas of leukoplakia involving the relatively superficial plane taking as little of the underlying mus-
vermilion border of most of the lower lip. Except for the palpable culature as possible, but ensuring that no 'button holes' take place
nodule at the site of the infiltrating cancer, the remaining lesion through the mucosa of the surgical specimen.
is only superficial.
As the specimen is mobilized towards the right-hand side,
Surgical excision of this lesion will require a V-excision at the dissection continues keeping uniform thickness of the excised
site of the palpable nodule, in conjunction with lip shave specimen until the edge of the V-excision is reached (Fig. 5.24).
procedure for excision of the vermilion border of the lower lip. Complete hemostasis is secured at this stage of the operation by
The outline of the incision is shown in Fig. 5.22. The operation electrocoagulating the bleeding points which are usually from the
can be performed under local or general anesthesia. If local dermal as well as the mucosal edge of the surgical detect.
anesthesia is used, the entire lower lip is infiltrated with 1%
At this point, using a number IS scalpel, a skin incision is made
Xylocaine with epinephrine (adrenaline) 1:100 000; however the
along the previously marked out V, then carried across to the
surgical incision must be marked out with a skin marking pen
right-hand side near the commissure of the mouth and com-
prior to infiltration of local anesthetic. The author prefers general
pleting the entire length of the incision on the labial mucosa
anesthesia because it allows more satisfactory control of the oper-
posteriorly (Fig. 5.25). The remainder of the surgical excision is
ative procedure, and avoids any distortion in the configuration of
then completed, again using electrocautery which, at the site of
the mucocutaneous junction of the lip. The operation begins with
the V, requires a through-and-through wedge of the lower li|)
the lip shave part of the procedure. A skin incision is made at the
excising the underlying musculature and the overlying mucosa
mucocutaneous junction of the lower lip beginning on the left-
posteriorly. Usually, the labial artery can be easily identified,
hand side of the patient and up to the edge of the proposed
clamped, divided and ligated to minimize brisk hemorrhage from
V-excision. A similar incision is made on the mucosal aspect of the
the vessel. I'ulling on the specimen must be avoided because if it

Fig. S.21 A nodular infiltrating squamous cell carcinoma of the lower lip. Fig. 5.22 The outline of the incision
Fig. 5.23 Excision begins w i t h a lip shave. Fig. 5.25 The procedure continues w i t h a V-excision.

Fig. 5.24 Dissection continues in a submucosal plane. Fig. 5.26 The surgical defect.

is pulled too hard during the dissection, unnecessary amounts of

the labial musculature will be resected resulting in a notched
deformity at the site of the surgical excision.
The surgical defect resulting from this excision is shown in Fig.
5.26. The labial artery requires ligation at both ends of the defect
of the V-excision. Adequacy of surgical excision is confirmed by
frozen section examination of the margins. Meticulous attention
should be paid to absolute hemostasis, otherwise bleeding and
hematoma will develop in the postoperative period.
Closure of the surgical defect begins with a fine nylon suture
taken through the vermilion edge of the skin defect at both ends
of the V-excision defect of the lower lip. The suture is placed and
held tight, hut not tied. This will allow accurate approximation of
the vermilion edges to avoid a notched deformity or inaccurate
approximation of the vermilion border of the reconstructed lower
lip. fraction is now applied to the ends of this skin suture to allow-
both sides of the surgical defect to collapse to permit accurate
placement of the muscular sutures. Once the muscular layer is
Fig. 5.27 The muscular layer is accurately reapproximated.
closed, the dynamic reconstruction for maintenance of com-
petency of the oral cavity is accomplished (Fig. 5.27).
Attention is now focused on mobilization of the labial mucosa allow easy separation of the mucosa covering the gum and the
which will be used in reconstruction of the new vermilion surface lower lip.
(Fig. 5.28). The oral cavity is opened generously, and large An Adson forceps is now used to grasp the upper edge of the
Richardson retractors are placed at the oral commissure on both labial mucosa and, using electrocautery, submucosal dissection of
sides to expose the gingivolabial sulcus. Electrocautery is used to Ibis bipedicled, labial mucosal flap is undertaken (Fig. 5.29).
place a relaxing incision in the gingivolabial sulcus as shown. The Meticulous attention is paid to the technique of dissection in the
labial mucosa is placed under tension by retracting it, while the submucosal plane, otherwise buttonholes would result in the mucosa
incision in the gingivolabial sulcus is made with electrocautery, to if the flap is too t h i n , or unnecessary musculature of the lower lip
Fig. 5.28 Mobilization ot the labial mucosa with a relaxing incision in Fig. 5.30 The accurate plane of dissection is superficial to the muscular
the gingivolabial sulcus. layer.

Fig. 5.29 Submucosal dissection is undertaken. Fig. 5.31 Adequate mobilization of the bipedicled mucosal flap provides
coverage of the vermilion surface.

would be taken with the flap if it is kept too thick. The accurate The entire vermilion border is thus restored with the mucosa of
plane of dissection is such that some minor salivary gland tissue ihe lower lip. Finally, the skin closure at the site of the V-excision
remains on the mucosal flap while the musculature remains intact is completed with interrupted, non-absorbable sutures. The intra-
(Fig. 5.30). The entire flap is mobilized through the length of the oral mucosal defect at the gingivolabial sulcus is left open to heal
incision in the mucosa of the gingivolabial sulcus; thus this by secondary intention.
becomes a hipedicled, labial, mucosal flap of the lower lip. Ihe surgical specimen in Fig. 5.33 shows complete stripping of
Adequate mobilization allows the labial mucosa to he retracted the lower lip in conjunction with a V-excision at the site of the
superiorly and everted out to restore the vermilion border (Fig. infiltrating cancer. The postoperative appearance of the patient
5.31). If there is excessive tension, then further mobilization is approximately eight weeks following surgery shows complete res-
necessary on both sides near the commissure of the mouth to give toration of the normal configuration of the lips and commissure
satisfactory eversion of the mucosa. Complete hemostasis must he with the mouth closed (Fig. 5.34). At the site of Ihe V-excision
ensured prior to closure of Ihe mucosa to the skin edge of the only a linear, vertical scar is noticeable. On opening the mouth,
surgical defect. The labial mucosal flap is sutured to the skin of the the mucocutaneous suture line becomes apparent (Fig. 5.35).
lower lip in a single layer with non-absorbable sutures (Fig. 5.32). the substance of the lower lip is preserved, and a satisfactory
Extreme care must be exercised for accurate approximation between vermilion border is restored. Accurate approximation of the mus-
culature of the lower lip prevents any notching at the site of repair
the mucosal and the skin edges to restore a new mucocutaneous
of the V-excision defect, and competency of the oral commissure
junction of the vermilion surface. Some trimming of the mucosa
has remained intact.
may be necessary at Ihe two lateral edges of the surgical defect.
Fig. 5.32 Skin and mucocutaneous closure is completed. Fig. 5.S3 The surgical specimen.

Fig. S.34 The postoperative appearance of the patient alter eight weeks. Fig. 5.35 The mucocutaneous suture line demonstrates the new
vermilion surface.

ABBE-ESTLANDER FLAP REPAIR

for deeply infiltrating tumors. A through-and-through excision is
performed so that a triangular piece of mucosa, similar to the
When more than 30% of the width of the lip is resected, recon- triangular piece of skin, is excised with the specimen. The prin-
struction of the lip requires mobilization of a flap from the ciple of Abbe-Kstlander flap repair is such that the width of the
opposite lip (Fig. S.36). When approximately two-thirds of the base of the triangular flap is half thai of the width of the base of
lower lip has been excised, it can be reconstructed by borrowing the triangular surgical defect. The flap is marked out on the upper
tissue equivalent to half the surgical deled from the upper lip. The lip on the same side; however it can also be obtained from the
technique has been popularized by Abbe for reconstruction of the opposite side of the upper lip if that is felt to be more appropriate.
upper lip, and Kstlander for the lower lip. The long axis at the site of closure is kept along the radial skin
The patient shown in F i g . 5.37 is an elderly gentleman with a lines around the oral cavity. Incision at the site of surgical excision
deeply infiltrating squamous carcinoma of the lower lip involving is made with a number 15 scalpel through both skin and mucosa.
the underlying musculature and the adjacent vermilion border The remaining excision is completed using electrocautery. A
warranting excision of nearly half of the lower lip. When the through-and-through wedge excision w i t h the underlying
mouth is open, the lesion appears to be clear of the oral commissure musculature is completed. Note that while the specimen is being
on the right-hand side, and therefore no specific measures are mobilized, it should not be grasped and pulled loo hard, otherwise
necessary for restoration of the commissure (Fig. 5.381. an undue amount of muscle of the lower lip would be excised due to
The proposed line of excision of the lower lip is marked out stretch and pull, leading to a notched deformity at the site of repair.
(Fig. 5.391. Note that the long axis of the V-excision is planned The surgical specimen shows a through-and-through resection
in such a fashion that a generous portion of the area of tumor of the lower lip (Fig. 5.40). The adequacy of resection is
involvement is excised while there is some sacrifice of the skin and confirmed by frozen section examination of the margins of the
the underlying musculature. A 1 cm margin at each end is desirable surgical defect.
Fig. 5.36 Mobilization of a flap from the opposite lip. Fig. 5.39 The proposed lines of incision for resection of the tumor and
elevation of the flap.

Fig. 5.37 An elderly gentleman w i t h a deeply infiltrating squamous Fig. 5.40 The surgical specimen.
carcinoma of the lower lip.

Fig. 5.38 The lesion is clear of the oral commissure on the right-hand Fig. 5.41 The full-thickness flap is elevated w i t h its pedicle on the labial
side. artery medially.

A skin i n c i s i o n is n o w m a d e at the p r e v i o u s l y m a r k e d o u t l i n e of f l a p ( F i g . S . 4 1 ) . I n c i s i o n o n the m e d i a l m a r g i n o f d i e flap, h o w -

the Abbe-Estlander flap o n t h e lateral aspect o f t h e u p p e r l i p . T h e ever, is d o n e w i t h e x t r e m e c a u t i o n a n d care, b e g i n n i n g at the apex
lateral incision i s deepened t h r o u g h b o t h the m u s c u l a t u r e a n d the o f the flap w o r k i n g t o w a r d s t h e v e r m i l i o n border i n order t o a v o i d
mucosa e x t e n d i n g f r o m the v e r m i l i o n border u p t o t h e apex o f t i l e i n j u r y t o t h e labial artery. A s m o b i l i z a t i o n o f t h e f l a p towards
Fig. 5.42 The Abbe-Estlander flap is rotated to fill the surgical defect.

Fig. 5.44 The muscular layers between the flap and lower lip, as well as
the donor site, are repaired.

Fig. 5.43 A fine nylon suture is taken through the vermilion edges for
accurate alignment.

Fig. 5.45 Closure of the skin incisions.

the vermilion border proceeds, it is desirable lo separate the TIOW sutured together with interrupted 3-0 chromic catgut sutures.
musculature of the upper lip with a hemostat and divide small Extreme care must be exercised in placing the catgut suture between
segments of the muscle fibers with scissors a little at a time. Once the right-hand side of the edge of the flap and the musculature of
the labial artery is identified, the other attachments of the mus- the lower lip near the commissure of the mouth lo avoid injury to
culature of the upper lip around the labial artery are divided under the labial artery in the pedicle of the flap.
direct vision still keeping the mucosa of the vermilion border After approximation of the muscular layer in the lower lip,
intact. Thus, the contents of the pedicle of the flap would be the closure of the donor site defect in the upper lip is undertaken (Fig.
labial artery, its accompanying vein and the musculature between 5.44). The mucosal layer is closed with interrupted chromic catgut
the artery and the vermilion border as well as the latter's mucosa. sutures followed by a muscular layer of interrupted 3-0 chromic
The labial mucosa on the medial aspect of the flap is also divided, catgut sutures. Accurate approximation of the vermilion border of
from the apex of the flap up to the vermilion border. the upper lip is not possible because of the still-attached pedicle
The Abbe-Estlander flap, thus mobilized, derives its blood of the flap. Skin closure is, however, completed in as accurate a
supply from the thin pedicle which remains attached to the upper manner as possible to avoid discrepancy between the commissure
and the vermilion border of the upper lip.
lip (Fig. 5.42). The flap is rotated 180" to fill the surgical defect in
the lower lip. Setting and approximation of the flap into the Closure of the skin incisions of the upper and lower lip is per-
delect of the lower lip begins by accurate approximation of the formed with 5-0 nylon interrupted sutures (Fig. 5.45). Chromic
vermilion edges of the flap and the lower lip. A line nylon suture catgut interrupted sutures are employed for closure of the mucosa
is taken through the vermilion edges between the Abbe-Estlander of the flap and the labial mucosa of the lower lip. The flap thus
flap and the surgical defect in the lower lip (Fig. 5.43), held tight remains attached to the upper lip through its pedicle leaving a
and retracted to allow accurate placement of the flap in the bridged pedicle between the upper and the lower lips. The patient
surgical defect. The muscular layer of the flap and the lower lip is must be warned preoperatively about this bridge so that in the
Fig. 5.46 The postoperative appearance of the patient three weeks after Fig. 5.48 The bridged pedicle providing blood supply from the upper
surgery.

Fig. 5.47 The bridged pedicle of the Abbe-Estlander flap. Fig. 5.49 The bridged pedicle is divided.

immediate postoperative period he does not inadvertently commissure and the bridge of the pedicle of the flap demon-
traumatize, disrupt or tear the pedicle of the flap. Because of the strating the vascular pedicle derived from the upper lip (Fig.
compromised size of the mouth, the patient has to resort to liquid 5.48). In approximately three weeks, the circulation of the flap by
foods and a blenderized diet due lo inability to open the mouth neovascularization is established to allow division of the bridged
completely. Skin sutures may be removed at approximately one pedicle. However, prior to undertaking the division, vascularity of
week. In the immediate postoperative period, the flap may look the flap must be checked by applying compression on the bridged
bluish and dusky, usually due to venous congestion. However, as pedicle with either a hemostat or a rubber band. If the flap turns
long as capillary tilling is present, the flap will survive and remain blue, then division of the pedicle should be delayed. Slight dis-
viable in its entirety. The postoperative appearance of the patient coloration of the flap is expected on compression of tiie pedicle;
al approximately three weeks after surgery is shown in Fig. S.46. however, if capillary blanching is present, then it is safe to divide
Note that the skin incision at the donor site in the upper lip has the pedicle.
healed very well with an almost imperceptible scar. Ihe flap is set Division of the bridged pedicle is relatively simple and can be
well and has rilled the defect very adequately restoring Ihe con- performed under local anesthesia. A hemostat is introduced
tinuity of the lower lip and the configuration of the mouth. On through the lateral opening of the oral cavity under the bridge
asking the patient to open the mouth, the bridged pedicle of the (Fig. 5.49). Using a scalpel, the pedicle is transected, releasing the
Abbe-Estlander flap becomes evident, demonstrating continuity upper lip from the attachment to the lower lip. The only bleeding
of the mucosa of the vermilion border between the flap and the in this maneuver is from the labial artery which is clamped and
upper lip (Fig. 5.47|. ligated. Small wedge excisions are performed to match and revise
A wooden stick is passed through the opening between ihc oral the raw areas at the site of the divided pedicle to facilitate primary
Fig. 5.50 Small wedge excisions are performed at the site of the divided Fig. 5.52 A large invasive squamous cell carcinoma of the lower lip.
pedicle.

Fig. 5.51 Accurate approximation of the vermilion edges is crucial for a Fig. 5.53 The incisions for resection and reconstruction of the lower lip
superior esthetic result. are outlined.

closure (Fig. 5.50). Accurate approximation of the vermilion commissures intact. The patient shown in Fig. 5.52 has a large
edges of both the upper and lower lips is vital for achieving an invasive squamous cell carcinoma of the lower lip in its central
optimal esthetic result (Fig. 5.51). All hough the size of the mouth two-thirds, with extension laterally on the vermilion border
is reduced somewhat, symmetry is maintained and excellent within a few millimeters of the commissure on both sides. The
functional and esthetic reconstruction of the lip is achieved by the surgical defect created by excision of this tumor results in a
use of this flap. through-and-through defect of the lower lip from the vermilion
When the oral commissure must be sacrificed along with border up to the gingivolabial sulcus involving approximately
excision of the lower lip tumor, then a non-bridged Estiander flap 80% of the central component of the lower lip.
can be employed. This will, however, result in rounding of the The principle of the Karapandzic flap reconstruction is
commissure which requires a secondary revision. The Abbe- mobilization and utility of the skin, soft tissues, and mucosa of
Estlander flap can be used in reverse when a lesion of the upper lip the lower portion of the nasolabial region which are shifted
is excised, whereupon the flap is elevated from the lower lip. medially, preserving the nerve and blood supply to the orbicularis
oris muscle which is rotated medially. Thus, the incisions for
elevation of this flap require mobilization of the skin and
KARAPANDZIC FLAP REPAIR
subcutaneous tissues superficial to the orbicularis oris muscle and
the mucosa deep to the orbicularis oris muscle, keeping the
Karapandzic flap repair for reconstruction of defects of the lower muscle itself intact with its nerve and blood supply preserved. Hie
lip is ideally suited in situations where 80% or more of the lower incisions for resection of the lower lip and reconstruction by
lip is resected in its central part, leaving the lateral ends near the Karapandzic flap repair are shown in Fig. 5.53. The lateral
Fig. S.54 The tumor is resected and skin incisions for the Karapandzic Fig. 5.56 Mucosal incisions are placed in the gingivolabial and
flap are placed. gingivobuccal sulcus on each side.

Fig. 5.55 The flap is elevated in a subcutaneous plane remaining Fig. 5.57 Mucosal, muscular and cutaneous closure of the lower lip is
superficial to the orbicularis oris. completed.

incisions lor elevation of the flaps follow the nasolabial skin crease permit medial mobilization of both the flaps for a midline closure.
and have to he modified in each patient depending upon the Repair of the surgical defect then begins with vertical midline
location of the skin crease in the nasolabial region. closure of the transected edges of the lower lip with accurate
Resection of the lower lip lesion is performed in the usual three- approximation of the vermilion border by a 5-0 nylon suture first.
dimensional fashion. Adequacy of resection is confirmed by This suture is held and used for retraction permitting approxi-
frozen section examination of margins of the surgical defect. The mation of the muscular layer of the two ends of the Karapandzic
skin incisions for elevation of the Karapandzic flaps are made with flaps, f o l l o w i n g approximation of the muscular layer, the
a scalpel (Fig. 5.54). Mobilization of the subcutaneous soft tissues cutaneous and mucosal closure on both sides of the reconstructed
and the skin component of the flap is meticulously undertaken lower lip are completed (Fig. 5.57). following this, reapproxima-
with an electrocautery, remaining superficial to the orbicularis oris tion of the suture line between the cutaneous margin of the flaps
muscle (Fig. 5.55). Avoiding division of the muscle fibers main- and the cutaneous margin of the chin and the nasolabial region
tains neuromuscular control of the orbicularis oris and thus is undertaken, accurately aligning the two sides, preserving
retains competency of the oral cavity. After adequate mobilization the esthetic continuity of the nasolabial folds (Fig. 5.581. The
of the skin and subcutaneous tissues of the flap on each side, postoperative result at approximately three months following
incisions are placed in the mucosa of the gingivolabial and surgery shows accurate restoration and reconstruction of the large
gingivobuccal sulcus on each side, again carefully preserving the delect of the lower lip with minimal esthetic deformity but
anatomic continuity of the orbicularis oris muscle (Fig. S.S6). with adequate restoration of the competency of the oral cavity
Sufficient length of the mucosal incisions must be performed to (Fig. 5.59).
Fig. S.58 The donor site defects are repaired in two layers. Fig. 5.59 The appearance of the patient three months following surgery.

BERNARD R E C O N S T R U C T I O N OF THE LOWER LIP

This operation is designed for tumors that are too extensive for
reconstruction using the Abbe-Estlander or Karpandzic flaps. The
lower lip may be excised in its entirety along with soft tissues and
skin of the chin, with the resulting defect closed by lateral cheek
flaps lo form a new lower lip. In order to set hack the commissures
and to prevent fish-mouth deformity, triangles of skin are excised
from both sides of the upper lip, preserving the mucous mem-
brane, to help form a new vermilion border (Fig. 5.60). The
distinct advantage of this operation is its ability to reconstruct
nearly the whole lower lip in a single-stage procedure. An obvious
disadvantage is reduction in the size of the orifice of the oral
cavity and a 'permanent smile' deformity of the lips particularly in
the edentulous patient.
The patient shown in Fig. 5.61 has a large primary squamous
cell carcinoma involving the entire thickness of the lower lip with Fig. 5.60 Plan of excision and reconstruction.
extension to involve the skin and soft tissues of the upper part of
the chin. The area of excision is outlined along with the intended
wedges of the skin to be excised from the upper lip near the
nasolabial skin crease lo facilitate advancement of the Bernard
flaps for reconstruction of the lower lip (Fig. 5.62). The resection
of the tumor is performed in the usual fashion. Adequacy of
tumor resection is confirmed by frozen section examination of
margins of the surgical defect.
The surgical defect shows a through-and-lhrough resection of
nearly seven-eighths of the lower lip (Fig. 5.63). Note that the
surgical excision on the labial surface goes right up to the gingivo-
labial sulcus. A generous portion of the skin of the chin and the
underlying soft tissues are also resected en bloc with the surgical
specimen.
When a significant portion of the skin of the chin is excised, it
is important to plan the lower incision on the chin in such a way
that the advancement flaps will allow satisfactory closure. Gen-
erally, a rectangular-shaped excision is preferred to facilitate closure.
However, a variety of other surgical incisions are available includ-
ing double triangles, etc. to aid reapproximation of the lateral
cheek flaps and repair the chin.
Fig. 5.62 The area of excision is outlined.

Fig. S.64 The completed closure.

Fig. 5.63 The surgical defect.

Triangular wedges of the skin and subcutaneous tissue are now RADICAL RESECTION OF THE LOWER LIP A N D
excised from the nasolabial crease on both sides. The base of the MICROVASCULAR FREE FLAP RECONSTRUCTION
triangle extends from the commissure of the mouth up to the
nasolabial crease depending upon the width of the cheek flap to
be mobilized medially. After excision of the triangular wedges of Massive primary or recurrent carcinomas of the lower lip with
the skin in this way, the mucosa from the inner aspect of these invasion of the overlying skin of the chin and the underlying
triangular wedges is incised, and the triangular flaps of mucosa of mandible require through-and-through composite resection with
the upper lip retrieved from these locations are shifted medially immediate reconstruction of the mandible, the overlying soft
along with the flaps. Now an incision is made in the lower tissues, and the skin of the chin as well as the lower lip to restore
gingivolabial sulcus on both sides, and both cheek flaps are facial contour and oral competency. The patient shown in Fig.
mobilized medially. In the center of the surgical delect, the apex 5.66 has recurrent carcinoma of the lower lip with invasion of
of the triangular part of the skin of the chin is mobilized by the skin of the chin and the underlying arch of the mandible.
appropriate wedge excisions on the chin to provide a satisfactory Through-and-through resection of the entire lower lip with the
closure. Closure of the musculature of the lip on both sides is skin of the chin and anterior arch of the mandible in conjunction
performed with interrupted chromic catgut sutures. The triangular with bilateral supraomohyoid neck dissections is required to en-
wedges of the mucosa from the upper lip are everted and rolled compass the recurrent tumor and regional lymph nodes. This
interiorly to provide the new vermilion surface. Mucosal closure is patient did have palpable metastatic lymph nodes at Level I in the
completed inleriorlv in the gingivolabial sulcus. The full-thickness prevascular facial lymph nodes on the left-hand side; however,
wedges created in the skin of the upper lip at the commissure are since the recurrent tumor invaded the entire lower lip, bilateral
closed in three layers on each side. The completed closure is supraomohyoid neck dissections were performed, flic surgical
shown in Fig. S.64. defect of this patient demonstrates the stumps of the mandible on
both sides as well as soft tissue and skin deficit created by surgical
The postoperative appearance approximately three months after resection of the tumor (Fig. 5.67). Hie surgical specimen seen
surgery shows the reconstructed lower lip with restoration of both from the anterior aspect shows wide excision of the skin of the
the size of the oral orifice and the vermilion border (Fig. S.6S). chin and the entire lower lip performed in continuity with

u,.i
 Fig. 5.68 The surgical
specimen, seen from
the anterior aspect.

Fig. 5.66 Recurrent carcinoma of the lower lip involving the mandible

Fig. 5.69 Posterior

view of the surgical
specimen.

Fig. 5.67 The surgical defect.

bilateral supraomohyoid neck dissections including submental component of the flap provides coverage of the skin of the chin
lymph nodes (Fig. 5.68). The posterior view of the surgical and has adequate soft tissue to restore the contour of the chin.
specimen shows the arch of the mandible resected in a monobloc The skin flap is folded over itself to create the lower lip and
fashion with the tumor of the lower lip including soft tissues of the edges of the skin flap are sutured to the commissure of the
the submental triangle (Fig. 5.69). residual upper lip. Alternatively, two microvascular free flaps may
A microvascular composite osteocutaneous flap from the fore- be used. A scapula or fibula free flap for bone and radial forearm
arm is ideal for reconstruction of a short segment of the mandible free Hap for skin. The postoperative appearance of the patient
and provides an excellent supple and soft skin flap for recon- approximately two months following surgery shows satisfactory
struction of the skin of the chin and the lower lip. The bony com- reconstruction of the contour of the chin providing an excellent
ponent of this composite flap consists of a split portion of the repair of the lower lip (Fig. 5.70). The lateral view of the face of
lower half of the radius bone which provides sufficient bone to the patient shows satisfactory restoration of the protrusion of the
chin for this through-and-through defect of the lower lip and
reconstruct the surgical defect in this edentulous patient. Two
anterior arch of the mandible (Fig. 5.71). Complex recon-
osteotomies are performed in this bone; however, the osteotomized
structions such as this require detailed preoperative planning of
segments are not quite stable to provide a sturdy bone repair and,
the reconstructive procedure to achieve a satisfactory post-
therefore, these hone segments are stabilized over a titanium A-O operative result.
plate to reconstruct the arch of the mandible. The cutaneous
THE LIPS 5

Fig. 5.70 The postoperative appearance of the patient two months Fig. 5.71 Lateral view of the face of the patient.
following surgery.

NASOLABIAL FLAP REPAIR FOR THE UPPER LIP The incisions for resection and reconstruction are outlined in
Fig. 5.73. The nasolabial flap is elevated longer than its anti-
cipated length so that the repair can be accomplished without
Defects of the skin and underlying soft tissues of the upper lip arc tension and the donor site defect closed with little distortion of
most amenable to reconstruction using an inferiorly based naso- the facial features.
labial flap. The latter is a highly reliable, axial skin flap which The surgical defect following excision of this lesion shows the
provides skin coverage and enough soft tissue replacement for the musculature of the upper lip in the depth of the defect (Fig. 5.74).
excised portion of the upper lip. However, one distinct dis- The nasolabial flap is rotated inferiorly and medially to fill the
advantage of this flap is that it does not restore muscular action of surgical defect. The donor site defect is primarily closed by mobil-
the upper lip, and thus there is functional deficit which persists. ization of the skin of the cheek. A two-layered closure is performed
However, the esthetic result is excellent. Thus, nasolabial flap using 3-0 chromic catgut interrupted sutures for subcutaneous
repair would be unsatisfactory for full-thickness resection of upper tissues and 5-0 nylon for skin (Fig. 5.75). The same patient's
lip defects. appearance approximately one year later (Fig. 5.76) shows a very
The patient shown in Fig. 5.72 has a recurrent basal cell gratifying result with the use of the nasolabial flap for repair of the
carcinoma of the skin of the upper lip on its lateral aspect. This skin defect of the upper lip. The donor site defect is barely per-
lesion was previously treated by electrodesiccation and curettage. ceptible and the contour of the lips and vermilion border appears
The lesion involves underlying soft tissues but does not infiltrate essentially normal.
through the musculature of the upper lip. The inferior margin of
the lesion approaches the vermilion border and, superomedially,
the lesion reaches the alar groove.

Fig. 5.72 A recurrent basal cell carcinoma of the skin of the upper lip. Fig. 5.73 The incisions are outlined.

166
Fig. 5.77 A sweat gland carcinoma of the upper lip.

Fig. 5.78 The surgical defect.

RESECTION AND RECONSTRUCTION OF THE UPPER LIP

WITH UNILATERAL BURROWS TRIANGLE REPAIR

The patient shown in Fig. 5.77 has a sweat gland carcinoma

involving the vermilion border of the left-hand side of the upper
lip and the adjacent skin with involvement of the underlying soft
tissues. Surgical resection of this tumor requires a through-and-
through excision of the upper lip extending from the right-hand
side of the midline up to within 1 cm of the oral commissure on
the left-hand side. The surgical defect following excision of this
tumor is shown in Fig. 5.78. Frozen section examination is per-
formed from the margins of the surgical defect to ensure adequacy
of resection. A Burrows triangle is marked out along the nasolabial
skin crease and the alar groove on the left-hand side with an
incision marked for advancement of the skin of the cheek for
reconstruction of the upper lip. Skin and soft tissues from the
Burrows triangle are excised and the skin incision on the left
cheek has been placed with mobilization of the subcutaneous
soft tissues, remaining superficial to the orbicularis oris muscle
(Fig. 5.79). Medial advancement of the residual upper lip of the
left-hand side and the mobilized soft tissues of the left cheek
provides satisfactory closure of the surgical defect (Fig. 5.80). The
vermilion border is accurately aligned first and then mucosal,
muscular and skin closure of the upper lip is performed. Finally,
the skin along the alar groove and the advancement incision on
the left cheek are closed meticulously in two layers (Fig. 5.81).
The postoperative appearance of the patient approximately three
months following surgery shows a very satisfactory reconstruction
of the resected portion of the upper lip with unilateral Burrows
triangle technique (Fig. 5.82).
Fig. 5.79 Skin and soft tissues from the Burrows triangle are excised, Fig. 5.81 Multilayered closure is completed.
and advancement incision is placed on the skin of the cheek.

Fig. 5.80 Medial advancement of the residual upper lip of the left-hand Fig. 5.82 The postoperative appearance of the patient three months
side. following surgery.

BILATERAL BURROWS TRIANGLE REPAIR OF THE

UPPER LIP

lull-thickness resection of the upper lip, up to one-third of its

width, is easily amenable lo repair by direct primary closure
similar lo the V-excision of the lower lip. However, when a larger
portion of the upper lip is resected, the Burrows technique is very
satisfactory for its reconstruction. The principles of reconstruction
are similar to the Bernard triangle repair. Triangular wedges of skin
between the alar groove and the nasolabial crease are excised
permitting lateral upper lip-cheek flaps to be mobilized medially
to accomplish the repair.
A patient with a primary infiltrating squamous cell carcinoma of
the skin and vermilion border of the upper lip in the region of the
philtrum is shown in F i g . 5.83. The tumor infiltrates the under-
lying musculature but does not perforate through the labial
mucosa.
The plan of surgical excision is outlined in Fig. 5.84 and shows Fig. 5.83 A patient with a primary infiltrating squamous cell carcinoma
a through-and-through resection of the upper lip, with proposed of the skin of the upper lip.
triangular wedges of skin to be excised from the nasolabial crease
adjacent to the nasal ala. The arrows indicate the extent of mobil-
ization and medial advancement of the residual upper lip on both (Fig. 5.86). If the triangular wedges arc accurately placed along
sides. The surgical delect following excision of the tumor shows a the side of the ala the scar of the closure goes right along the
through-and-through resection of the central part of the upper lip. groove of the ala and minimizes esthetic deformity. However, the
Note that the mucosal incision goes right up to the gingivolabial size of the oral orifice is reduced and some tension on the upper
sulcus (Fig. 5.85). lip is to be expected.
After excision of the triangular wedges of the skin, the lateral The postoperative appearance three months later (Fig. 5.87)
cheek flap and residual upper lip are advanced medially, and a shows excellent healing and reconstruction of the upper lip, which
three-layered closure is performed using interrupted chromic is now distinctly smaller in length than before causing backward
catgut sutures for mucosa and muscles and 5-0 nylon for skin pull and recession in this edentulous patient. Note that the mid-
Fig. 5.84 The plan of surgical excision is outlined. Fig. 5.86 The lateral cheek flap and residual upper lip are mobilized
medially after excision of Burrows triangles.

Fig. 5.85 The surgical defect. Fig. 5.87 The postoperative appearance three months later.

line scar at the philtrum is well healed, so there is minimal esthetic

deformity and an imperceptible scar along the nasal ala.
The same patient's appearance eight months later following
fabrication of an upper denture to push the upper lip out and
restore the configuration Of the lips is shown in Fig. 5.88. This is
a very gratifying result of reconstruction following resection of a
sizable tumor of the upper lip.

RECONSTRUCTION OF THE ORAL COMMISSURE

Full-thickness resection of the cheek including the oral com-

missure presents a significant functional and esthetic deformity
for the patient. A variety of reconstructive techniques are available
for restoration of the full-thickness of the cheek, including: a
folded forehead flap, pectoralis myocutaneous flap with skin
graft, or a microvascular radial forearm free Hap. None of these Fig. 5.88 The same patient's appearance eight months later.
Fig. S.89 The incisions for the Estlander flap and for its insertion into Fig. 5.91 The flap is rotated 180°
the reconstructed left cheek are marked out.

Fig. S.90 The Estlander flap is elevated in the usual fashion. Fig. 5.92 The flap is further rotated 90° to a total rotation of 270° and is
inserted in the left cheek to recreate the oral commissure. The surgical
defect at the donor site is seen in the upper lip.

reconstructive methods, however, restore the competency of the excision of the skin in the reconstructed left cheek to create a
oral commissure, and drooling remains a problem because of lack space for insertion of the Estlander flap is marked out.
of competency of the oral cavity. However, a modification of the The Estlander flap is elevated in the usual fashion keeping its
Estlander flap, described by Converse as the 'over-and-out pedicle on the left-hand side (Fig. 5.90). The blood supply is
technique', can be used to reconstruct the commissure and restore derived from the superior labial artery. It is a lull-thickness
oral competency. through-and-through flap providing coverage of the skin as well
The patient shown in Fix- 5.89 bad recurrent carcinoma of the as mucosa and vermilion surface. The flap is rotated 180°
cheek mucosa, which had previously failed radiation therapy. A demonstrating its very thin pedicle (Fig. 5.91), and then further
through-and-through resection of the cheek including the oral rotated 90° to a total rotation of 270° (Fig. 5.92), and inserted in
commissure was performed, and the cheek was reconstructed the space created between the two layers of the reconstructed left
using a folded forehead flap, which provided inner lining as well cheek by excising the skin edge. The Estlander flap is now sutured
as external skin coverage. The patient's appearance approximately in two layers leaving a transient bridge between the upper lip and
three months after forehead flap reconstruction shows restoration the commissure on the left side. The surgical defect in the upper
of the cheek and closure of the surgical defect, but lack of oral lip at the donor site of the Estlander flap is visible in Fig. 5.92. A
competency due to the absence of the oral commissure. wooden stick is inserted through the opening in the upper lip
between the bridge of the Estlander flap and the reconstructed
The proposed outlines for both the Estlander flap as well as
Fig. 5.9J The final closure of the surgical defect at the donor site. Fig. 5.95 The patient's appearance with open oral cavity.

Fig. 5.94 The same patient's appearance approximately three weeks Fig. 5.96 The same patient's appearance with mouth closed shows the
later. reconstructed oral commissure.

commissure demonstrating the pedicle of the flap. Estlander flap to t h e i n n e r l i n i n g of the cheek, as in a V-Y plasty,
The final closure of the surgical defect at the d o n o r site d e m o n - p u l l i n g t h e mucosa a n d creating a h o r i z o n t a l crease in the flap.
strates the i m m e d i a t e appearance of the patient on the o p e r a t i n g F o l l o w i n g c o m p l e t i o n o f restoration o f t h e commissure, the
table (Fig. 5 . 9 3 ) . The b r i d g e of the pedicle divides the oral c a v i t y patient's appearance w i t h t h e o p e n oral c a v i t y is s h o w n g i v i n g
into two separate o p e n i n g s . acceptable size w i t h c o m p l e t e c o m p e t e n c y o f t h e reconstructed
The same patient's appearance a p p r o x i m a t e l y t h r e e weeks after commissure (Fig. 5.95).
this operative procedure shows the small bridged flap still The same p a t i e n t is s h o w n in F i g . 5 . 9 6 w i t h the m o u t h closed
attached t h r o u g h its pedicle to the upper l i p ( T i g . 5 . 9 4 ) . T h e g i v i n g a n acceptable esthetic appearance w i t h reconstruction o f
pedicle of the flap is d i v i d e d , a n d t h e c o n f i g u r a t i o n of the c o m - t h e c o m m i s s u r e a n d restoration of f u l l c o m p e t e n c y of the oral
missure is achieved by s u t u r i n g t h e apex of t h e mucosa of the cavity.
Fig. 5.97 Survival by stage: squamous cell carcinoma of lips. Fig. 5.98 Patterns of failure: squamous cell carcinoma of lips.

RESULTS OF TREATMENT four percent of patients with Stage I disease arc cured at five years.
Even with Stage IV disease, a 50% survival is achieved.
Approximately 15% of patients fail initial therapy. The patterns
Since a majority of patients w i t h cancer of the lip present at an
of failure arc shown in Fig. 5.98. Local recurrence and regional
early stage for diagnosis and treatment, excellent results are
lymph node metastasis are the most common sites of treatment
achieved by appropriate initial therapy. Overall, 85% five-year
failure. Salvage treatment is often successful and should be
survival is achieved for cancer of the lip following surgical treat-
aggressively undertaken for this tumor with an excellent potential
ment. Survival by stage of disease is shown in F i g . 5.97. Ninety-
for long-term cure.