Surgical and functional outcome of extensive resection of upper lip carcinoma

Surgical and functional outcome of extensive resection of upper lip carcinoma

Gamal I. El-Habbaa,a MD; Hazem Sobieh,a MD;

Hussein G. El-Gohary, a MD; Ahmed Zeidan,a MD; Nashwa Emarah,b MD;

a) Department of General Surgery, Benha University, Egypt. b) Department of  Pathology, Benha University, Egypt.

Abstract

Objectives: To evaluate aesthetic and functional outcome of ipsilateral fan flap for upper lip reconstruction after extensive excision of cancerous lesions

Patients & methods:  The  study included  17 patients; 11 males and 6 females with mean age of 64.2±7.1  years; 12 patients had basal cell carcinoma and 5 patients had squameous cell carcinoma and 8 patients had associated morbidities.  Surgical resection was performed with safety margin adjusted according to intraoperative print cytology performed for all cases; fan flap was fashioned so as to include the angle of the mouth as the pivot for flap rotation, upper labial advancement  flap was prepared for completion  of closure of the resultant defect and cheek advancement  flap was fashioned for closure of the defect that resulted after fan flap fashioning. All patients underwent functional and aesthetic evaluation including the ability to whistle, blow the cheek and to suckle the tube, and their satisfaction with the circumference of the mouth when fully opened and with the commissural appearance.

Results: All patients had primary  surgical excision and immediate  repair. Operative data included mean safety margin distance of6.9±1.6 mm, mean resultant defect in relation to lip size was 56±6%, mean operative time was 146.2±18.8 min and mean operative blood loss was

266.5±49.7 cc. Five  patients had postoperative  (PO)  surgery-related  morbidities  for a rate of 29.4%; 3 patients had wound infection  with small length wound dehiscence in one patient and 2 patients developed microstomia. Mean PO follow-up period was 27.9±10. 7 months. No cancer or surgery-related mortalities were reported. Mean PO satisfaction score was 10.8±2.4;

5 patients had score <10, while 12 patients had score >10.

Conclusion: Ipsilateral fan with contralateral advancement flaps for upper lip reconstruction after extensive resection for upper lip carcinoma provides acceptable functional and aesthetic outcome.

Key words: Cancer lip, reconstruction, fan flap, functional, aesthetic outcome.

Introduction:

The upper and lower lips are prominent facial features of significant importance for esthetic and functional reasons. Defects of the lips are typically  caused by either trauma or neoplasm; however, lip reconstruction poses a particular challenge to the surgeon in that the lips are the dynamic center of the lower third of the face. Their role in aesthetic balance, facial  expression,  speech,  and deglutition  is not replicated  by any other tissue substitute.

Therefore,   proper  restoration   of  lip  form and function post-injury is of paramount importance.l,2

Both lips, but especially the lower lip, are at risk for cutaneous malignancy because of their prominent location. Lip cancer is second only to skin cancer in terms of frequency  in the head and  neck region.  Both sequamous cell carcinoma and basal cell carcinoma were commonly seen in the upper lip. Surgery is the treatment of choice for most of these cancers;

however, treatment of such malignancies creates a spectrum of defects that must be meticulously  addressed by the reconstructive surgery. These defects can be classified as small, medium, and large, and the optimal reconstructive  method  is typically  based on this  distinction.  Depending  on  the  size  of the defect and the patient characteristics, reconstructive   options  include  primary closure, local tissue transfer, and free tissue transfer.3,4

The goals of lip reconstruction are both functional and aesthetic, and the surgical techniques employed are often overlapping. The aesthetic goals of lip reconstruction  are to provide adequate replacement of external skin while maintaining  the aesthetic balance of the vermiliocutaneous  junction and lip aesthetic units. The functional goals of lip reconstruction   are  to  maintain  intraoral mucosal  lining  and  to  preserve the  surface area of the oral aperture. The competence of the  orbicularis  muscle  sphincter  must  also be maintained,  as this is critical to achieving a functional recovery. Ideally, cutaneous sensation is preserved or reestablished to provide proprioceptive feedback for speech, animation, and management of secretions.5,6

Established  methods  of reconstruction yield good results, but often involve multiple steps, which can be cumbersome in certain populations;  hence, efforts have been  made to improve and simplify reconstructive techniques.7

The current study aimed to evaluate the aesthetic and functional outcome of ipsilateral fan flap for upper lip reconstruction after extensive excision of cancerous lesions

Patients and methods:

The present study was conducted at General Surgery  Department,  Benha  University hospital  since  Jan  2006  to  March  2010  to allow a minimum follow-up period of at least

6 month for the last case operated upon. The study was assigned to include patients with extensive upper lip squameous or basal cell carcinoma involving 2::40% of the surface area ofthe upper lip and approved by preliminary histopathological biopsy examination.

All patients underwent full history taking, complete clinical examination with special regard to head and neck examination for cervical nodal involvement. All patients underwent   MRI  examination   of  head  and neck with examination ofthe upper chest for nodal involvement. Patients who had nodal involvement, distant metastasis and those who had lesions extending for <40% of the surface areaofthe upper lip were excluded ofthe study. Laboratory investigations including complete blood  count,  liver  and  renal  function  tests were performed. All patients were referred to complete otorhinolaryngological and dental examination. Patients with systemic co­ morbidities including hypertension, diabetes mellitus and chest diseases were adjusted preoperatively  and were maintained on their medication postoperatively.

Local examination of the lesion included site, size, margins and encroachment on the vermilion  line  or  the  angle  of  the  mouth. Also, infiltration of the inner labial mucosa was also documented.

All surgeries were conducted under general inhalational anesthesia with oral cuffed endotracheal intubation with the tube inserted through the contralateral angle of the mouth and the tube cuff was inflated maximally to completely   obstruct   the   airway   passages. All patients had upper pharyngeal and oral packing  and  received  40  mg  ondansetrone to prevent postoperative  vomiting  and 8 mg dexamethasone to prevent airway and vocal cords edema. Preoperative intravenous broad spectrum antibiotic was given and continued

2 days after surgery.

Surgical procedure:

Surgical resection was performed with safety margin adjusted according to result of intraoperative  print  cytology  performed  for all cases; excision involved the full thickness down to the mucosa. Preservation of the neurovascular supply of the lower lip was hardly tried to maintain supply for fan flap. Then, fan flap was fashioned so as to include the angle of the mouth as the pivot for flap rotation. Upper labial flap was prepared to be used as advancement flap for completion  of

closure of the resultant defect through edge approximation started by suturing both edges of  the  mucosa  using  interrupted  3/0  PDS suture,  followed   by  muscle  approximation with  tension  free  suturing  as much  as possible and lastly the skin was closed using interrupted sutures.  Cheek advancement flap was fashioned for closure of the defect which resulted after fan flap fashioning. Pharyngeal packs  were removed prior to completion  of skin closure to allow the anesthetist to assure that  no  accumulated  blood  was  around  the tube because after wound closure and jaw fixation   with  head  bandage  the  tube  and suction will be performed blindly.

All patients received adequate postoperative  analgesia  and  anti­ inflammatory drugs to minimize edema that may endanger the suture line. All patients received  their  immediate  postoperative  care at ICU to guard against breathing problems until they were stable and transferred  to the

Figure (1): Preoperative appearance of upper lip sec showing areas of necrosis

and fungations. Areas of hemorrhage

were noticed. Preoperative incision marks for ipsilateral fan flap and contralateral advancement flap. Both angles ofthe mouth are preserved.

wards. Patients were allowed oral fluid and homogenized foods using suction few hours after surgery and up to 5-days later. On the

3rd  postoperative  day  wound  was  exposed

and vitality of the flaps was assessed and patients were discharged  and asked to dress the wound using povidine iodine daily till complete wound healing.

All patients underwent functional and aesthetic evaluation including the following items:  the  ability  to  whistle,  the  ability  to blow the cheek, the ability to suckle the tube, their satisfaction  with the  circumference  of the mouth when fully opened and with the commissural  appearance.  Each item was graded using 4-point scale with 0 indicating inability  or  poor  satisfaction,   1  indicating poor ability or partially satisfied, 2 indicating acceptable   outcome   and  3  indicating  full ability and high satisfaction and a total score was calculated ranging between 0 and 15.

Figure (2): Mass excised with safety margin with preservation of the ipsilateral angle of the mouth.

Figure (3): Both designed flaps were prepared with assurance of preservation of the ipsilateral angle of the mouth.

Figure (5): Immediate PO appearance showing positioning of both flaps to cover the excision area and ipsilateral advancement-rotational  flap to close the defect resulted from fan flap fashioning.

Ipsilateral angle ofthe mouth is preserved with adjustment of the vermillion line..

Results:

The study included  17 patients; 11 males and 6 females with mean age of 64.2±7.1; range: 53-74 years. Nine patients were ASA grade I, 5 patients were ASA grade II and 3 patients were ASA grade III. Twelve patients had basal cell carcinoma  and 5 patients had squameous cell carcinoma. Eight patients had

Figure (4): Fan flap was positioned.

Figure (6): PO appearance 3 months after surgery, both angles ofthe mouth were preserved and on line without narrowing ofthe oral commissural opening allowing excellent functional and satisfactory aesthetic outcomes.

associated morbidities; 5 patients were type-2 diabetics and 2 of them had previous cardiac attack, 3 patients were hypertensive and one of them had renal function impairment. Six males were chronic heavy cigarette smokers. No patient had cancer elsewhere in the body or had history of surgery for similar lesions, Table(l).

Table (1): Patients' enrollment data.

Data are presented as mean±SD & numbers; ranges & percentages are in parenthesis.

All     patients      had     primary      surgical excision  and immediate repair. Operative procedures were completed smoothly without intraoperative problems or complication. All lesions   were  excised   with  arbitrary   safety margin  that  was  extended   according to  the result of the immediate frozen  section  if required.   Mean  safety  margin  distance   was

6.9±1.6;  range:   5-10   mm.   Mean   resultant

defect  in relation  to lip size  was 56±6.4;  45-

65%. Three patients  had defect area <50% of the lip size, 9 patients had defect area which ranged  between  50 and  60%  of lip size  and

5 patients  had  defect  area  >60%  of lip size. Mean operative time was 146.2±18.8; range:

120-185 min  and mean  operative  blood  loss was   266.5±49.7;  range:    200-350    cc.   No patient required  blood transfusion, Table(2).

Table (2): Operative data.

Data are presented as mean±SD & numbers; ranges & percentages are in parenthesis.

All patients received their immediate postoperative care at ICU for a mean duration of   3.4±1.3;   range:   2-6   hours.   Oral   fluid intake  was allowed  after  a mean  duration of

5.4±0.8; range: 4-7 hours. All patients were discharged  after   wound   exposure  on   the

3rd  postoperative day  and  assurance of flap viability. Patients were asked for daily twice dressing with povidone iodine and to continue their  treatment for  associated co-morbidities in addition  to broad spectrum antibiotics and anti-inflammatory drugs. Patients  or near relative   were  asked  to  notice   any  change of  color,  wound  dehiscence, difficulty of breathing and  to  take  oral  fluid  diet  using small spoon  for five days and to attend to the outpatient clinic on the 6th PO day unless no complications occurred.

Five patients  had postoperative surgery­ related   morbidities  for   a   rate   of   29.4%. Two patients had mild wound infection that responded to conservative treatment and  did not  affect  flaps   viability.   One  patient   had small  length   wound   dehiscence  in  relation to  the   contralateral  advancement  flap   and

the  patient   was  re-admitted to  the  hospital for control  of diabetes  and wound  associated infection  and after subsidence of infection wound repair was undertaken successfully. Microstomia was  reported  in  two   patients who had large lesions that required  wide excision  with wide safety  margin  because  of their squameous cell carcinoma.

Mean  postoperative follow-up period  was

27.9±10.7; range:  6-45  months.  Throughout follow-up period  two  patients  died,  the  first was a diabetic  female  patient  who developed hyperglycemic hyperacidotic coma that precipitated  cardiogenic  shock   that   failed to   respond   to   treatment  and   patient   had died  three  days  after  developing coma.  The second  patient  was  diabetic  cardiac  patient who had acute  myocardial infarction but unfortunately she  died.  However, no  cancer related  mortalities were reported.

Mean postoperative satisfaction score was

10.8±2.4; range: 6-14. Five patients had score ranged between  5 and 10, 7 patients had score more than  10 but less than  12 and 5 patients had score more than 12, Table(3).

Table (3): Postoperative functional and aesthetic score.

Data are presented as mean±SD & numbers; ranges & percentages are in parenthesis.

Discussion:

Seventeen  cases of squameous  and basal cell carcinoma of upper lip were collected throughout  the  study  period; there  were  11 basal cell carcinoma and 6 squameous cell carcinoma, a finding indicated increased frequency of basal cell carcinoma in upper lip which is different from the frequency reported in the  lower  lip and  could be  attributed  to the difference in the predisposing factors for both localities  pathology. In hand with such frequency,  Czeminski  et  al.8   reported  that of 4337 new cases, the dominant tumor type was squameous cell carcinoma at the external lower lip and intraoral lip mucosa and basal cell carcinoma  on the  upper lip. Moreover, the study included 12 males (70.6%) and 5 females (29.4%), a similar gender-dependent frequency  was reported by Czeminski et al.8 who  found  most  cases  of  cancer  lip  were found among men (61.4%).

The study design relied on selective basis to  include  only  patients  free  of  nodal  or distant metastasis so as to avoid the need for neck  block  dissection  which  may  endanger flap blood supply. Also, the flap fashion was based on performing ipsilateral labial artery­ based fan-flap  including the ipsilateral angle of the mouth to safeguard it and upon rotation of the fan considering  its pivot for rotation was the angle  of the  mouth so  inducing no site change for that angle. Moreover, the contralateral  advancement flap  of the  upper lip allowed maintenance of the site of the ipsilateral angle of the mouth and provided symmetry ofboth angles.

The applied technique provided acceptable

results   manifested   as   symmetrical   angles of the  mouth maintained  on the same  level without  dropping  or elevation.  Microstomia was reported by 2 patients with a frequency of 11.8% and was unavoidable  because the extensive  resection   of  a  large  squameous cell carcinoma and necessity for wide safety margin.   However,   such   microstomia   was acceptable   functionally   and   both   patients found no difficulty to acclimatization to their oral  commissural  orifice  without  need  for second  stage  augmentation.  Three  patients developed   wound    infection   that    caused short-segment  wound  dehiscence  in  one of them, all of the three patients were diabetics but  responded  well  to  extensive  control  of diabetes and dressing with antibiotic therapy and   patient   who   had   wound   dehiscence had successful  wound  repair, for a total  PO surgery-related complications rate of 29.4%.

Evaluation  of PO functional  and satisfaction outcome revealed acceptable outcome with a total score of 10.8; 12 patients had score of >10 while the other 5 had score of <10, these 5 patients included the two patients   developed   microstomia    and   the other 3 were less satisfactory by functional outcome with special regard to the ability to blow their cheek, or to whistle, however, they were satisfied with the aesthetic appearance and such functional defect could be attributed to weakness of orbicularis oris due to aging process because inquiry of preoperative  data revealed the presence of such complaint preoperatively and they attributed it to the presence ofthe lesion.

The obtained  results  coincided  with that