CHAPTER 08: HEAD AND NECK Flashcards
What is the T classification of oral / oropharyngeal cancers?
Tx = Cannot assess
T0 = no evidence of tumour
T1 = less than 2cm
T2 = 2-4cm
T3 = >4cm
T4 Tongue = extrinsic muscles, fixed tongue or mandible invaded
T4 Lip = through cortical bone, inf alveolar nerve, floor of mouth, facial skin i.e. chin, nose
T4a = Invades locally (e.g., through cortical bone, into deep [extrinsic] muscle of tongue [genioglossus, hyoglossus, palatoglossus, and styloglossus], maxillary sinus, and skin of face)
T4b = Invades masticator space, pterygoid plates or skull base or encases the carotid artery
[Note: Superficial erosion alone of bone/tooth socket is not T4)
What is the N & M classification?
Nx = Regional nodes not assessed N0 = No regional nodes N1 = single mobile ipsilateral node < 3 cm diameter N2a = single mobile ipsilateral node 3-6 cm N2b = multiple mobile ipsilat not > 6 cm N2c = Bilat or contralat mobile node 3-6cm N3 = any node > 6cm or any fixed node Mx = mets not assessed M0 = no distant mets M1 = distant mets
How are H&N cancers staged?
Stage I - 75 – 95%
T1
N0
M0
Stage II - 60 – 65%
T2
N0
M0
Stage III - 40 - 50%
T3
N0
M0
T0, T1, T2 or T3
N1
M0
Stage IV - 10 - 30%
T4
N0 or N1
M0
Any T
N2 or N3
M0
Any T
Any N
M1
What are the principles of recon?
Why reconstruct?
o Restoration of form and function
o Enable more aggressive treatments
o Palliation
Immediate vs. delayed reconstruction?
o Immediate gets better results
o But delayed allows planning, prefabrication
Define the patient
Define and map the defect (defect is the main predictor of post-op function not reconstruction)
What are the non-surgical modes of treatment?
- Radiotherapy
- Electromagnetic radiation
- Irreparable double strand breaks in DNA
- Indications: close or +ve margins, perineural / vascular invasion
- given postop
- Modes of delivery: fractionated, intensity modulated, bolus - Chemotherapy
- neoadjuvant, adjuvant
- for close margins / extracapsular LN spread - Chemoradiotherapy
- neo, adjuvant, concomitant - Immunotherapy
- cell signal inhibition, antiangiogenesis - Lasers & PDT (light activated chemotherapy)
What are the LN levels of the neck?
Level 1 = (a) Submental + (b) Submandibular triangle
- Below inferior border of mandible
1a below bellies of digastric, 1b above
Level 2 = Upper jugular
- lateral border of Sternohyoid to post border of the SCM
- From skull base to carotid bifurcation (clinical landmark = HYOID)
- Includes upper jugular and jugulodigastric nodes
2A +B = divided by the accessory nerve
2B = posterior to nerve
Level 3 = Middle jugular
- lateral border of Sternohyoid to post border of the SCM
- bifurcation of carotids to omohyoid (clinical landmark = CRICOTHYROID MEMBRANE)
- Contains the middle jugular nodes
Level 4 = Lower jugular
- lateral border of Sternohyoid to post border of the SCM
- from omohyoid to clavicle
- contains lower jugular nodes and thoracic duct L
Level 5 = Posterior triangle
- anterior border = post edge of SCM
- Post border = anterior edge of trapezius
- Inferior = clavicle
- Contains cervical plexus and transverse cervical artery
Level 6 = Anterior neck
- hyoid
- suprasternal notch
- medial border of carotid sheath
Level 7 = superior mediastinum
How do you manage N0 neck?
- Palpation
- Imaging - mainly USS
- FNA
- Treat if high risk of occult mets (>20%)
- How to treat? Depends on Mx of primary
- Site, size and morphology dependent
How do you manage node +ve neck?
- Surgery or radiotherapy → same effectiveness but worse side effects with radiotherapy
- Brachytherapy good if not close to mandible
SOUTAR RCT - T1&2 ELND vs wait - ELND = increased survival
What are the predictors of nodal disease?
- High T stage
- Sites → tongue, floor of mouth, tonsils, PNS, retromolar trigone. Nasopharynx and tonsil behave very differently form the other oral tumours ? more lymphatics
- Better prognosis for palate, gingiva
- Thicker tumours
What investigations are there for neck nodes?
- Clinical 70% effective
- CT/MRI 85% Nodes over 1 cm
- US + FNA 95% effective
Management of the Unknown Primary
History
- Smoking drinking, oral lesions, voice changes (larynx and thyroid), pain, ulceration, trismus (=lingual nerve perineural spread), ↓wt, swallowing problems, night sweats (lymphoma).
Examination
- Intra–oral: (with head light) tumour, ulcer, thickenings, tongue wasting, deviation
- Nasendoscopy: and look for signs of other secondaries
- General: cachexia
What are the investigations for unknown primary?
- CXR (hilar nodes in lymphoma)
- MRI/CT H+N
- PET-CT identify 60% of unknown primaries
- Rigid Panendoscopy for 1ry and other synchronous lesions. Nasopharynx, Oropharynx, Hypopharynx, Oesophagus, Stomach, Larynx, Trachea/bronchi
- Biopsy any abnormal areas + pyriform fossa, nasopharynx, tonsillar fossa, base of tongue
- Cervical node FNA -> open biopsy – (use LND compatible incision in case of extracapsular spread)
Isolated cervical mets with unknown primary - what biopsies should be take?
Classic sites (Waldeyer’s Ring (Fossae) & Tongue)
- Rosemuller Fossa - nasopharynx (behind opening of Eustachian tubes) Needs bilateral Level III
- Base of tongue
- Tonsilar fossa
- Piriform fossa (Pharynx) Level III
What is the treatment for unknown primary?
o Obtain histological confirmation = neck dissection
o If still can’t find primary, treat neck with radiotherapy or surgery (LND) + radio to possible primary sites.
What radiological investigations are useful in H&N cancers?
X-rays - only pick up late bony invasion
OPG
PA mandible
MRI Tissue excited with high-power magnet When magnetic field switched off the excited photons emit a radiofrequency wave T1 images fat = white T2 images water = white
CT
Malignant nodes have radiolucent core and radio-opaque periphery
PET & PET-CT
Radiolabelled Glucose to identify metabolising cells
FDG – Fl-18 labelled 2-F-2 deoxy-d-glucose
Identifies up to 60% of unknown primaries
Also good for regions prone to submucosal disease e.g. Head & Neck
High sensitivity, but low specificity (picks inflammation up)
CT-PET – co-registration of Pet images with CT images
How did neck dissection evolve?
Crile 1906 - described RND
Bocca & Pignataro 1967 - functional ND
1991 - neck dissection terminology standardised
What types of incisions for neck dissection do you know?
Breach - Apron
McFee - parallel hi low transverse
Hayes-Martin - chevron / sideway H
Conley - Y
What are the fascial layers of the neck?
Superficial cervical fascia • Deep cervical fascia – Superficial layer • SCM, strap muscles, trapezius – Middle or Visceral Layer • Thyroid • Trachea • esophagus – Deep layer (also prevertebral fascia) • Vertebral muscles • Phrenic nerve
DRAW!
What important structures lie over the SCM?
Which muscle is a useful landmark for identifying important structures?
- External jugular v.
- Greater auricular n.
- Spinal accessory n.
Digastric muscle Posterior belly is superficial to: • ECA (facial & lingual arteries) • Hypoglossal nerve • ICA • IJV
Anterior belly
• Landmark for identification of mylohyoid for dissection of the submandibular triangle
Marginal mandibular nerve
Spinal accessory nerve
MMN
• Most commonly injury dissection level Ib
• 1cm anterior and inferior to angle of mandible
- At mandibular notch
- Deep to fascia of submandibular gland (superficial layer of deep cervical fascia)
- Superficial to adventitia of facial vein
SAN
• Crosses IJV
• Occipital artery crosses SAN
• Descends obliquely in level II (forms Level IIa and IIb)
• Penetrates deep surface of SCM
• Exits posterior surface of SCM deep to Erb’s point
• Enters trapezius ~5 cm above clavicle
Phrenic nerve
Sole nerve supply to diaphragm
• C3-5 -> diaphragm
• Runs obliquely toward midline on anterior scalene
• Covered by prevertebral fascia
• Lies posterior and lateral to carotid sheath
Hypoglossal nerve
- Motor nerve to tongue
- Lies deep to the IJV, ICA, CN IX, X, and XI
- Curves 90deg and passes b/t IJV and ICA
- Common site of injury - floor of submandibular triangle, just deep to duct
What is the clinical significance of cervical LN levels?
Suggested by Suen and Goepfert (1997)
• Biologic significance for lymphatic drainage depending on site of tumour
Level I
• Lower lip, FOM, ventral tongue – Ia
• Other oral cavity subsites – Ib, II, and III
Level II
• Oropharynx and nasopharynx – IIb
– XI should be mobilized
• Oral cavity, larynx and hypopharynx – may not be necessary to dissect IIb if level IIa is not involved
Level IV subzones
• Level IVa nodes – increased risk in Level VI
• Level IVb nodes – increased risk in Level V
Level V subzones
• Oropharynx, nasopharynx, and skin – Va
• Thyroid - Vb
How did the Academy’s Committee for Head and Neck Surgery and Oncology standardise the classification system in 1991?
1) RND = All lymph nodes in Levels I-V + spinal accessory nerve (SAN), SCM, and IJV
= the standard basic procedure for cervical lymphadenectomy against which all other modifications are compared
2) MRND = Modifications of RND which include preservation of any non-lymphatic structures
3) SND (Selective) = one or more groups or levels of lymph nodes preserved
4) END (Extended) = removal of additional lymph node groups or non-lymphatic structures relative to RND
Academy’s Classification
1) Radical neck dissection (RND)
2) Modified radical neck dissection (MRND)
• MRND1 - keep XI (Accessory n.)
• MRND2 - keep XI + either SCM or IJV
• MRND3 - keep XI + both SCM and IJV
3) Selective neck dissection (SND) • Supra-omohyoid type • Lateral type • Posterolateral type • Anterior compartment type
4) Extended radical neck dissection
What other classifications do you know?
Medina, Spiro
When are different NDs indicated?
RND
- Extensive cervical involvement or
- matted lymph nodes with gross extracapsular spread and invasion into SAN, IJV, or SCM
MRND
– Clinically obvious lymph node metastases
– SAN / SCM / IJV not involved by tumor
– Intraoperative decision
RND vs MRND Type I (Andersen)
- 5-year survival and neck failure rates
for RND (63% and 12%) not statistically
different compared to MRND I (71% and 12%)
END
- carotid artery invasion
- hypoglossal or digastric muscle resection
Which SND is indicated for different N0 H&N carcinomas?
Selective neck dissection
- Indicated for N0 if primary lesion >20% risk of occult metastasis
- Oral T1 N1
– Reduce postsurgical shoulder pain and shoulder dysfunction
– Improve cosmetic outcome
– Reduce likelihood of bilateral IJV resection if contralateral neck involvement
- Supra-omohyoid type (oral ca)
- Lateral type (oropharynx, hypopharynx, supraglottis, and larynx)
- Posterolateral type (cutaneous & sarcomas)
- Anterior compartment type
(Selected thyroid, parathyroid,subglottic, laryngeal with subglottic extension & cervical oesophagus)
What are the different types of neck dissection skin incisions?
Apron (Breach) Half-apron / Hockey stick Conley Y Double Y H MacFee (1 parallel & under mandible, 1 above clavicle) Y incision (inf limb = over SCM) Schobinger, Modified Schobinger (inf limb = over posterior triangle)
Learn Jatin Shah's incisions A. Transverse high - supraomohyoid middle - jugular - larynx low - comprehensive - thyroid B. Modified - parotid (Blair + lazy S curving lower into neck to do supraomohyoid dissection) C. Posterolateral (S) D. Comprehensive - RND (Y)
What are the indications for adjuvant radiotherapy?
- positive histology in neck dissection
- N2 disease
- Extracapsular spread
- Oral T3 and T4
What are the complications of neck dissection?
Specific Early intra-op
- Bleeding
- Air Embolus: vein (immediate ligation, pack, head down, turn head to left side)
- Pneumothorax
- Carotid artery injury
- Nerve injury (phrenic, vagus, brachial plexus, lingual, hypoglossal, glossopharyngeal)
Specific Intermediate
- Skin-flap necrosis
- Carotid blow out: often fatal, inc risk pts with salivary fistulas, radiotherapy
- Chyle leak = damage to thoracic duct. Rx Fat free diet or TPN
- Salivary fistula
Specific Late
- Scar contracture
- Neuroma (cervical plexus)
- Shoulder pain syndrome (reduced incidence if CN XI preserved)
- Cellulitis and facial oedema (IJV excised)
Talk me through how you perform a radical neck dissection
Skin incision
- Mastoid Process to opposite SCM keeping 2 fingerbreadths below angle of mandible.
- Trifurcation point is kept posterior to carotid where possible.
How does Jatin Shah classify neck dissection?
Comprehensive - remove contents of all 5 levels
- Classic Radical
- Extended Radical
- Modified Radical 1,2,3
Selective
- Supraomohyoid
- Levels 1-3 + submandibular gland
- oral cavity tumours
- avoids risk to thoracic duct (level 4 on left) - Jugular = Anterolateral
Levels 2,3,4
- laryngeal, hypopharyngeal tumours - Anterolateral
- Levels 1-4 common for T1/2 N0 oral tumours as don’t go to 5 - Anterior
- Levels 2, 3, 4 + tracheo-oesphageal
- thyroid tumours - Posterior = Posterolateral
- Levels 2,3,4,5
- posterior scalp tumours - Central
- Level 6
How do you manage intra-op bleeding from upper end of IJV?
- Tell anesthetist: bleeding problem.
- Prevent air embolus by pressure on vein distally.
- Isolate bleeding point with suction and local dissection.
- If possible, repair or oversew IJV defect.
- If not possible, plug with finger or gauze
- Apply pressure while finishing dissection
- If still bleeding plug area with segment of SCM.
- May require thoracic surgeon to enter superior mediastinum.
- IJV may retract into temporal bone (pack with Surgicel, locate posterior belly of digastric over hole).
How do you perform a radical neck dissection?
Posterior triangle
Skin incision
- Vertical limb is curvilinear and ends at midclavicular point.
- Posterior flap is elevated subplatysmal until anterior border of trapezius.
- Spinal accessory nerve is preserved at this point in MRND – seen coming into anterior edge of post. triangle
- Dissection of soft tissue from floor of post. triangle exposing splenius capitus and levator scapulae.
- Superior edge of SCM is detached from mastoid process.
- At the lower end, transverse cervical artery and vein are tied off. Inferior belly of omohyoid is divided allowing posterior scalene muscle to be exposed.
- Lower end of external jugular ligated
- Roots of cervical plexus come into view – these are preserved until phrenic nerve and motor branches of the cervical plexus are identified. Cutaneous branches of cervical plexus then ligated (to catch accompanying vessels)
- Brachial plexus comes into view – dissection here is easy because of loose areolar tissue
- Post triangle dissection now complete.
How do you perform a radical neck dissection?
Anterior dissection
- Anterior part of transverse incision now made.
- Sternal head of SCM exposed using large loop retractor – this, along with manubrial and clavicular attachments is then divided with diathermy – loose areolar tissue between muscle and carotid aids protection of the vessel.
- Vessels entering the anterior skin flap near the clavicle are preserved (branches of int. mammary which supply skin flap)
- SCM pulled upwards to reveal carotid sheath. IJV blunt and sharp dissected out
- Prox. end of transverse cervical artery and vein ligated
- Thoracic duct dissected out and ligated
- Tissue pulled out from behind IJV to keep it in continuity with specimen
- Common carotid and vagus identified and kept out of the way medially whilst bottom end of IJV is double-ligated.
- Middle thyroid vein enters medial IJV - ligated
- Dissection continues upwards along carotid sheath until skull base
- This reveals the hypoglossal nerve, superior belly of omohyoid leading to hyoid – omohyoid detached from here
- Superior thyroid artery preserved, but vein is ligated.
- Anterior dissection now complete
How do you perform a radical neck dissection?
Supraomohyoid & mandibular gland
- Superior flap elevated
- Marginal mandibular nerve is identified over the submandibular gland (2 fingerbreadths below and 2 fingerbreadths anterior to angle of mandible) – preserved by retracting it upwards with skin flap.
- Facial artery and vein ligated along with branches of occipital artery that enter specimen.
- Contents of submandibular triangle (level 1 nodes, submandibular gland, its nerve supply and Wharton’s duct) are dissected, preserving lingual and hypoglossal nerves
- Tail of parotid is separated or transected along posterior belly of digastric which can then be retracted upwards
- Occipital artery may need to be divided if it is very low.
- Accessory nerve divided and ligated (vasa nervorum) near jugular foramen
- Upper end of IJV double ligated.
- Irrigation, drains x2 (one over trapezius, other over strap muscles), haemostasis
- Closure and airtight dressing
- Specimen pinned out on to board, labeled, marked etc.
What are the complications?
Fistulae Wound breakdown XI nerve palsy XII nerve palsy Carotid blow-out & if survive like to have CVA Airway obstruction
What is the anatomy of salivary glands?
Parotid
- Deep, superficial lobes & tail
- Separated by facial nerve
- surrounded by continuation of deep cervical fascia
- Serous acini mainly
- Stensen’s duct - opens at 2nd maxillary molar
Submandibular
- In submandibular triangle
- Mucous & Serous Acini
- Wharton’s Duct - into anterior floor of mouth
Sublingual
- In anterior floor of mouth
- Multiple ducts of Rivinus → Bartholin’s duct → Wharton
Minor glands
- 600 - 1000 of them
- Mainly mucous secreting
- Mucous Acini
What factors are suggestive of malignancy?
- 3% of all head and neck malignancy
Factors suggestive of malignancy
- Pain, Obstruction, infection, Nerve involvement (but pleomorphic (benign) can rarely cause palsy too), Invasion of other structures, Bleeding from the duct, Rapid progression.
Bimanual palpation
Name some benign salivary tumours
PAWOM
- Pleomorphic Adenoma (benign mixed)
- Most common - 65% of all salivary lesions, 80% of benign
- Slow growing, painless
- 30-50yr olds
- Rarely - Invasion of nerve → palsy
- Superficial parotidectomy better – Simple enucleation → high recurrence (tumour is not encapsulated)
- EXCISE - risk of enlargement and CNVII - Adenoma
- Cannalicular Adenoma (75% in upper lip)
- Basal Cell Adenoma (75% in parotid)
- Females 2:1
- May look like a mucocoele
- Surgical excision usually curative
3. Warthins – Adenolymphoma (papillary cystadenoma lymphomatosum) - 10%of all parotid neoplasms - 10% bilateral - 10 x risk in smokers - 10:1 M:F - 10% malignant - Minimal margin excision or superficial parotidectomy (elderly - observe)
- Oncocytoma
- rare - <1% - Monomorphic adenoma
- similar presentation to pleomorphic
- various cell types
- almost exclusive to men 50-70 years
Name some malignant salivary tumours
MAMPAL
- Mucoepidermoid
- 30% of all malignant parotid tumours
- Well differentiated → limited invasiveness rarely mets
- Intermediate grade → similar to well diff SCC
- Poorly differentiated high grade malignancy, local invasion and regional spread. - Adenoid Cystic Carcinoma
- 20%
- Cribriform = best prognosis
- Tubular = intermediate
- Solid form = worst prognosis
- Skip lesions along facial nerve common, prone to perineural invasion
- V high recurrence rate +/- lung mets - Malignant Mixed Cell (Carcinoma ex pleomorphic adenoma)
- Usually after a benign lesion present for over 10yrs - Polymorphous Low-grade adenocarcinoma
- Acinic Cell Carcinoma
- Lymphoma
- Asociated with Sjogren’s
How do you perform a superficial parotidectomy?
Blair incision - upper anterior border of ear → preauricular crease → mastoid → hyoid (2cm below mandible)
Elevation of skin flap (raise SMAS, down to parotid fascia).
Separation of parotid tail (from SCM & digastric). Preserve post. facial vein
Isolate and preserve facial nerve (tragal pointer, 1cm anterior and inferior to tragal pointer, note that it’s quite deep).
Antegrade approach - trace forward from 1cm deep to tragal pointer
Retrograde approach - trace back from cervical br (retromandibular vein), marginal br (lower mandible, over facial artery), buccal br (Stensen’s duct) - if lesion if very large in retromandibular area
Buccal branch - in line tragus and corner of mouth, identify Stensen’s duct
Tell me something about nasal and paranasal sinus tumours
3% of head and neck malignancy
More common in Far East
Affect : nasal cavity, maxillary sinus, ethmoid, sphenoid, frontal sinuses
Benign: Osteoma. Fibroma, Fibrous Dysplasia
Osseous malignancy: Osteogenic Sarcoma, Ewing’s sarcoma.
Connective tissue (malignant): Chondrosarcoma, Fibrosarcoma, Malignant fibrous histiocytoma (MFH), Rhabdomyosarcoma
Epithelial Tumours: SCC, Adenocarcinoma, Mucoepidermoid carcinoma, MM
How do you manage these tumours?
Stage (MRI, CT)
Biopsy
Ohngren’s line - plane b/t medial canthus & angle of mandible. Above line = poorer prognosis (more vital structures invaded)
Weber - Fergusson incision for maxillary sinus
How are invasive mandibular tumours managed?
History → loose teeth, numb lip, pain, (inf alveolar nerve invasion)
Exam → Big tumour, path #
X-ray → OPG, PA mandible → specific not sensitive, false -ve
CT → specific more sensitive
MRI
Operative assessment →
- If periosteum peels away easily = no invasion (Rim excision)
- If periosteum adherent = suspicious (Segmental excision)
If periosteum invaded consider rim resection (marginal mandibulectomy) or segmental resection.
How does bone invasion occur?
Bone invasion occurs
1. soft tissues = infiltrative spread
2. lymphatic channels = embolic spread
3. nerves = permeative spread
4. occlusal surface after tooth extraction
DXT may disrupt periosteal integrity → tumour spread
What is the resultant defect?
Defects
- Segmental
- Rim
- Atrophic
- Pathological Fracture
What resection techniques are there?
What is the resultant defect?
Rim resection
- resect alveolus with preservation of body of mandible. Only if tumour is abutting bone. NOT after radiation as this alters the pattern of tumour spread.
- not for edentulous patients
Segmental resection
- for significant bone invasion or after radiation. Needs reconstruction.
- Classify defects:
o C = central segment between the canine teeth
o L = lateral segment not including condyles
o H = lateral and Horizontal segment including the condyle
o Many are combination (LC - central and lat but not condyle, LCL = large central but no condyles, HC – central & lateral including condyles)
o Central segment most important to reconstruct → if not get Andy Gump deformity
o Least important → condyles
What is the history of lip reconstruction?
- 1597 – Tagliacozzi – distal pedicle from arm to lip
- 1768 – Louis – wedge excision & direct closure
- Late 1700s – Chopart – local advancement – failed
- 1838 – Sabattini – lip switch from lower to upper lip
- 1898 – Abbe
- 1857 – von Bruns – curvilinear nasolabial flaps
- 1853 – Bernard cheek advancement, von-Burrow modification
- 1872 – Estlander – for lower lateral / commissure
- 1957 – Gillies – fan flap
- Karapandzic - myoneurovascular pedicled advancement flap
- 1974 - Harii and Ohmori- microvascular free tissue transfer for lip reconstruction
What are the principles of reconstruction?
- No bone recon
- span w contoured recon plate, pec major wrap
- eventually extrudes, not suitable w DXT - Non-vascularised
- bone graft max 5cm
- autograft, allograft, alloplast
- titanium tube filled with cancellous bone - Vascularised - pedicled / free
- Vascularised bone
- Free fibula
- DCIA
- RF
- Scapular - Osseointegrated implants
Name the anatomical landmarks of the lip
NL fold, philtral columns and groove, tubercle, cupid’s bow, white roll, commissure, vermilion, labiomental fold
Name the muscles acting on the lip
Orbicularis Oris
• 2nd branchial arch.
• forms sphincter encircling oral aperture
• fibres decussate in midline at modiolus
• Extrinsic fibres intermingle with buccinator
• Intrinsic fibres → incisive and mental slips
• Acts to form a whistling expression
Elevators • Levator labii superioris alaeque nasi • Levator labii superioris • Levator anguli oris • Zygomaticus major • Zygomaticus minor
Depressors
• Depressor anguli oris
• Depressor labii inferioris
• Mentalis
What are the nerves of the lips?
Motor • Upper Lip - levators – buccal VII • Lower Lip - depressors – marginal mandibular VII • Orbicularis supplied by both • Platysma - cervical br of VII
Sensory
• upper – infra-orbital (maxillary V)
• lower – mental (inf. alveolar – mandibular V)
What is the blood supply to the lips?
- Superior & inferior labial arteries from facial artery
- 1 mm posterior to the white roll and 1 mm deep to the mucosa of the lip.
- deep to the orbicularis oris muscle
What is the lymphatic drainage of the lips?
- Upper lymphatics are unilateral, lower is bilateral
- Both lips drain into submandibular and submental nodes
- Upper lip also drains into peri-parotid and preauricular nodes
What are the aesthetic units of the lip?
Lip has 4
- Lateral wings between philtral columns and nasolabial folds
- Philtrum between philtral columns
- Lower lip between vermillion and labiomental fold
- Vermillion between vermillion border and the dry-wet line
What are the considerations of lip reconstruction?
- Oral competence
→ drooling (loss of sensation innervation and depth of lower sulcus) - Adequate access to oral cavity
Microstomia → difficult eating, dentures, teeth cleaning and repairs. Stretching devices can be used esp. if < 50% - Communication
- Cosmesis
What do the lesions on the upper lip tend to be? And lower?
- Upper lip lesions tend to be BCCs
- Lower lip lesions tend to be SCCs
- More metastasis with commissural or mucosal
What is Gilles’ principles of lip reconstruction?
What do the algorithms of lip reconstruction depend on, i.e. how do you classify lip defects?
Restoration is designed from within outwards. The lining membrane must be considered first, then the supporting structures and finally the covering.
Classification depth size location subunits
Anatomic considerations blood supply sensation muscular function motor innervation topographic subunits
How do you reconstruct >50% defects?
Over 50% full thickness • Webster’s modification of Bernard lip reconstruction = Bernard-Burows / Webster-Bernard (PRS 1960) • Gilles’ fan flap • Karapandzic (1974 BJPS) • McGregor • Nakajima • Abbe (1898 Med Rec) • Estlander (Arch Klin Chir, 1872) • Perialar flaps
- Free transfer - radial forearm & PL sling
- Replantation
What are the reconstruction options for:
- mucosa only
-
Mucosa only
• excised vermillion and mucosal advancement
Less than 30% width
• wedge / pentagon excision, direct closure
Between 30 and 50% • Johansson’s step technique • Karapandzic flap • Abbé flap • Estlander flap
