Squamous cell carcinoma of lower lip reconstructed with bilateral fan flap

Bhatt D Supreet¹, Semmia Mathivanan², Mustafa I Merchant³, Niranjan S Patil^4
1 Department of Head and Neck Oncology, Gujarat Cancer Research Institute, Ahmedabad, India
² Department of Oral and Maxilofacial Surgery, Chettinad Dental College and Research Institute, Kancheepuram, India
³ Deparment of Surgical Oncology, Basil Onco Care, Surat, India
⁴ Department of Maxillofacial Surgery, (Dental Specialty) Bombay Hospital, Mumbai, India

The most frequent tumor related to the lips is the squamous cell carcinoma, with the lower lip more commonly involved than the upper lip. The pivotal risk factors having impact on the prognosis include size of the tumor, histopathological type and grade, perineural invasion, regional lymph node metastasis, and local recurrences. Management of lip cancer and reconstruction is a surgical challenge.

Keywords: Bilateral fan flap, lip carcinoma, lower lip reconstruction

How to cite this article: Supreet BD, Mathivanan S, Merchant MI, Patil NS. Squamous cell carcinoma of lower lip reconstructed with bilateral fan flap. Ann Maxillofac Surg 2019;9:211-3

How to cite this URL: Supreet BD, Mathivanan S, Merchant MI, Patil NS. Squamous cell carcinoma of lower lip reconstructed with bilateral fan flap. Ann Maxillofac Surg [serial online] 2019 [cited 2019 Jul 18];9:211-3. Available from: http://www.amsjournal.com/text.asp?2019/9/1/211/260350

Introduction

Lip cancers are among the most common malignancies in the head-and-neck region. Squamous cell carcinoma (SCC) constitutes 90% of all malignant oral tumors. SCCs most commonly involve lip after skin in the head-and-neck region. The incidence increases with age, reaching its peak in the seventh and eighth decades. The lower lip is affected far more frequently (80% to 95%) than the upper lip (2% to 12%) or commissure (1% to 15%). The majority of SCC of the lower lip stems from the vermillion border.^[1] In our country, SCC of the lip is more common than other parts of the world, which is probably due to the excessive intake of tobacco and chewing of pan, gutkha, or betel nuts.

Among histologic types observed, SCC is identified in 95% of all cases, whereas basal cell carcinoma more common on the upper lip and adenocarcinomas arising in the minor salivary glands constitute the rarest types.^[2] Prognosis and cure rates have been progressively increasing with early diagnosis and proper treatment planning. The significance of neck dissection and meticulous evaluation for the presence of metastasis in the regional lymph nodes have been emphasized, and this determines the prognosis and success of the treatment.

Reconstruction is a surgical challenge, especially for advanced and extended lesions. The aims of lip reconstruction should be to maintain oral competence, maintain maximum oral aperture, maintain mobility, maintain sensation when possible, and maximize cosmesis.

Case Report

A 60-year-old female patient reported with the chief complaint of proliferative growth in the lower lip for the past 10 years [Figure 1]. It was associated with discomfort and burning sensation while having spicy food. History revealed that she was a pan chewer for >20 years. On clinical examination, there was an ulceroproliferative growth involving the entire lower lip, largest diameter measuring around 6 cm. Level III lymph nodes were palpable. Histopathology was suggestive of well-differentiated SCC. The patient underwent excision of the entire lesion [Figure 2] and reconstructed with bilateral fan flap [Figure 3] and [Figure 4] after obtaining informed consent. Moreover, as a second stage of surgery, bilateral selective neck dissection was done after 3 weeks allowing time for the flap take-up. Margins of the specimen sent for histopathological evaluation were free of tumor. The patient was followed up for 2 years with no recurrence.

Figure 1: Lower lip showing extensive lesion Click here to view

Figure 2: Wide excision Click here to view

Figure 3: Flap reflection Click here to view

Figure 4: Postoperative closure Click here to view

Discussions

Reconstruction of the lip is a surgical challenge. The patient treated has to be provided with two essential elements: sufficient esthetic quality for the lip to go unnoticed on the face and recovery of labial function. Oral competence is the prime function, enabling the patient to feed normally, without dribbling saliva or food, and to express him or herself easily.^[3]

Thus, lips loss is a major deformity producing a devastating alteration of normal life. In addition to this, lips are highly vulnerable to trauma and the contractile process of burns. Like eyelids and digits, they are delicately structured and easily distorted.^[4]

Many lip repairs utilize the adjacent cheek muscles, as was pioneered by Gillies and later modified by McGreger. In the 1920s, Gillies described a classic fan flap using a full-thickness pedicle that allows redistribution of the remaining lip during the reconstructive effort and emphasized the use of a similar or like tissue.^[5]

Gillies fan flap is an extended version of the Estlander flap. It carries the commisure and lower lateral lip inward for the more medially located lower-lip defects. Like the Estlander procedure, the resulting commisure is distorted and the lower lip is shortened. The flap has superiorly based pedicle that provides additional tissue to the lip so that microstomina is avoided. Because of the re-orientation of the orbicularis oris muscle, a lack of motor function and minimal return of sensation occurs in this portion of the flap. Buccal advancement is often necessary to recreate the border between the vermilion and the red and white portions of the lip. Gillies fan flap rotates into position with the resected lip margin sutured to the residual medial lip. The advancement of the flap rotates the angle of the mouth with the flap.^[4]

As for defects larger than 2/3 or involving the total lip and not involving the chin area, flaps from adjacent cheek or chin muscles (depressor anguli oris flaps) may be a reasonable option, especially in those patients who cannot tolerate longer and more sophisticated procedures. In total lower lip loss with preserved commissurres, with or without chin involvement, and if the patient's general condition allows, a free radial forearm flap is recommended.^[5]

Bilateral fan flaps are popular methods described in the literature. The fan flap entails transposition of the nasolabial skin and mucosa into the lower lip after division of the orbicularis muscle. However, the fan flap is a completely denervated flap;^[5] hence, the sphincter action of the lip may be reduced. The movements of the lip with emotions are somewhat distorted.

Although free flaps are done immediately following tumor resection, they are not a single-stage procedure, and additional procedures such as vermilion reconstruction and revisions will always be needed. Vermillion reconstruction can be done by many techniques. One method may be suitable for one patient and not suitable for the other. Therefore, each case should then be treated on its own merits.^[5]

Lower lip SCC is not perceived as an aggressive carcinoma since it grows slowly, easily diagnosed, and treated effectively. Two important factors that affect survival are local and regional control, i.e. negative surgical margins and neck dissection. Cervical lymph node metastasis is present in 5-10% of lower lip SCC at the time of diagnosis. Many centers do not recommend elective neck dissection because of low occult metastasis in lower lip carcinoma.^[6]

Elective neck dissection (as a prophylactic procedure), also known as extensive dissection, should be performed if palpable lymph nodes are present. Suprahyoid dissection (Levels I, II, and III) is considered adequate for elective treatment of mouth tumors, but it may not be sufficient in the presence of metastases or it may be too aggressive when elective treatment involves both sides of the neck in an elderly patient. Kutluhan et al. also concluded that it is important to perform elective neck dissection to patients with no neck as much as resection of the primary tumor.

We hereby conclude that this case was treated with complete excision and selective neck dissection; we had good results with no recurrence and good flap take-up. We had reduced oral competence and movements. Secondary commissuroplasty was not executed due to age of the patient.

Acknowledgment

The authors would like to thank the Gujarat Cancer Research Institute, Ahmedabad, for the successful contribution in bringing out this manuscript.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 

References

1.	Düzgün S, Ünlü E, Pekdemir İ, Yilanci S, Ünlü RE. Management of Squamous Cell Carcinoma of The Lower Lip: Analysis of Five Years' Experience (78 Patients) and Review of The Literature KBB-Forum 2013;12.
2.	Dos Santos LR, Cernea CR, Kowalski LP, Carneiro PC, Soto MN, Nishio S, et al. Squamouscell carcinoma of the lower lip: A retrospective study of 58 patients. Sao Paulo Med J. 1996;114:1117-26.
3.	Malard O, Corre P, Jégoux, Durand N, Dréno B, Beauvillain C, et al. Surgical repair of labial defect. European Annals of Otorhinolaryngology, Head and Neck Diseases 2010;127:49-62.
4.	Mangi NA, Ghilzai MK. Functional comparison between karapandzic and Gillies technique in lower lip tumors. Pak J Surg 2012;28:38-42.
5.	Rifaat MA. Lower lip reconstruction after tumor resection; a single author's experience with various methods. J Egypt Natl Cancer Inst 2006;18:323-33.
6.	Kutluhan A, Kiriş M, Kaya Z, Kisli E, Yurttaş V, Içli M, et al. Squamous cell carcinoma of the lower lip and supra-omohyoid neck dissection. Acta Chir Belg 2003;103:304-8.

Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]