One stage reconstruction of large lower lip carcinoma, with local flaps

doi:10.4236/ojst.2013.37058

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Open Journal of Stomatology, 2013, 3, 344-346 OJST

http://dx.doi.org/10.4236/ojst.2013.37058 Published Online October 2013 (http://www.scirp.org/journal/ojst/)

One stage reconstruction of large lower lip carcinoma,

with local flaps

Mergime Prekazi Loxha1, Fellanza Gjinolli1, Osman Sejfija1, Aida Rexhepi2, Zana Agani3

1Department o f Maxillofacial Surgery, Uni v ersity Clinical Center of Kosova, Prishtina, Kosova

2University Clinical Dentistry Center of Kosova, Prishtina, Kosova

3Department o f Oral Surgery, University Clinical Dentistry Center of Kosova, Prishtina, Kosova

Email: [email protected]

Received 29 July 2013; revised 29 August 2013; accepted 15 September 2013

Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is

properly cited.

ABSTRACT

Squamous cell carcinoma (SCC) of the lower lip is a

frequently diagnosed malignant pathology in the

maxillofacial region. It is a slow-growing cancer, and

can be diagnosed and treated easily and effectively;

however, early treatment is important because its

mortality rate is 10% - 30%. Reconstruction for a

large lower lip defect is surgically challenging, espe-

cially reconstruction with local flaps. Here, we pre-

sent a 52-year-old male with a large T3 SCC, which

started 13 years before this treatment and involved

nearly all of his lower lip, oral commissure and upper

lip. It was reconstructed by local flaps with good aes-

thetic and functional results. The lip was recon-

structed with a combination of a Karapandzic flap on

one side and a contralateral Webster cheek advance-

ment, using a functional neck dissection on the tumor

side and supraomohyoid neck dissection contralater-

ally. Histopathology results of the neck were negative

for metastasis. We were satisfied with the aesthetic

and functional results of the neck.

Keywords: Lower Lip Reconstruction; Local Flap ; Lip

Cancer; Metastasis

1. INTRODUCTION

Squamous cell carcinoma (SCC) of the lower lip is one

of the most frequently diagnosed malignant pathologies

in the maxillofacial region. After skin cancer, lip cancer

is the second most frequent cancer in the maxillofacial

region [1,2]. Those with T1 and T2 lesions have better

prognoses [3]. As lower lip SCC is slow-growing, it can

be diagnosed and treated easily and effectively; however,

its early treatment is important because its mortality rate

is 10% - 30%.

The recommended protocol regarding clinically nega-

tive necks of patients with lower T1/T2 carcinomas is

“wait and see” [4]. However, the treatment protocol for

patients with T3/T4 carcinomas is tumor excision with

neck dissection, as metastases are more likely. Precise

diagnosis of malignant pathologies in the maxillofacial

region, and evaluation of possible metastasis in suscepti-

ble lymph nodes of the neck are critical in choosing the

best treatment for those patients and predicting their

prognoses [5-7]. Reconstruction of a large lower lip de-

fect is surgically challenging, particularly in maintaining

oral competence and preventing sialorrhea [8,9]. Few

cases of SCC that involved both lips and oral commis-

sure reconstructed with local flaps have been reported.

2. CASE PRESENTATION

A 52-year-old man came to our department with a large

tumor that involved almost all of his lower lip, right oral

commissure and part of his right upper lip. He reported

the tumor to have started 13 years previously as a small

lesion on his right lower lip, which had slowly enlarged.

He reported no symptoms such as pain, or hemorrhage.

He had not visited a physician, but had used an ointment

made by an “alternative doctor” for a short period of

time 4 years before. As the mass began to grow more

quickly six months previously, he decided to visit our

department.

At admittance, physical examination showed a large

T3 lip mass that involved nearly all of his lower lip, right

oral commissure and part of his right upper lip (Figure 1

and 2). Regional lymph nodes were not palpable.

Results of an incisional biopsy showed SCC, Grade I.

A neck ultrasound showed a positive lymph node (17

mm × 7.5 mm) in the right submandibular region. We

did not biopsy the lymph nodes seen in ultrasound.

Panoramix results for bone involvement and native lung

OPEN ACCESS

M. P. Loxha-maxillofacial et al. / Open Journal of Stomatology 3 (2013) 344-346 345

X-rays were both negative.

We performed a radical excision of the total lower lip,

leaving only 0.5 cm of the lip on the left side, right

commissure and almost half of the upper lip. We also

resected the basis of the mandible, as it was very close to

the tumor (Figure 3).

We performed a modified neck dissection at the right

side, and supraomohyoid neck dissection on the left side

(Figure 4).

For the lip reconstruction we used local flaps, with a

Webster cheek advancement flap on the right side (Fig-

ure 1) and Karapandzic on the lef t (Figure 2), with good

aesthetic and fun ctiona l results. Histop atholog y results of

the dissected tissue in the neck were negative for metas-

tasis. Despite the long history of the disease, we found

no positive cervical lymph nodes. The early postopera-

tive period continued without complications, the wound

appeared to be healing by first intention (Figure 5). Six

weeks after surgery, the patient underwent radiotherapy.

A clinical examination showed no sign of recurrence or

palpable lymph nodes after 4 months (Figure 6).

3. DISCUSSION

Squamous cell carcinoma is one of the most common

malignant tumors; however, SCC that involves near-to tal

upper lip, lower lip and oral commissure is rarely seen [8].

Figure 1. Webster cheek advancement flap planning on right

side.

Figure 2. Karapandic flap planning on left side.

Lip cancer is usually diagnosed early because it is visible.

There are few case reports with large lower lip carcino-

mas. Squamous cell carcinoma can grow rapidly and

spread along the orbicularis oris muscle and across the

oral commissure to the opposite lip. Advanced cancers

require multimodal treatment. No gold standard for re-

construction of both upper and lower lips has been estab-

lished [8]. Procedure selection for surgical reconstruction

of lip defects depends on the location and extent of the

defect, and the surgeon’s preference [10]. Management

of lip defects usually involves reconstruction with the

remaining opposite lip but no existing studies describe

simultaneous reconstruction of both upper and lower lips.

Achieving both oncologic and reconstructive goals of lip

reconstruction in large defects that involve both upper

and lower lips is difficult. Some authors prefer lip recon-

struction using free tissue transfer, which is an attractive

option when the lip defect is associated with loss of other

aesthetic units and/or mandibular bone loss. Their opin-

ion is that use of local tissue for subtotal lower lip resto-

ration creates problems such as microstomia, and facial

and commissure distortion [11].

In the case presented here, we were satisfied with the

aesthetic and functional results. After two weeks ( Figure

5) and after four months (Figure 6), we were pleased

with opening of th e mouth of the patient; also there were

no palpable lymph nodes on the neck. Advantages of

using local flaps in cases like this is less surgery time,

less donor site morbidity, less expensive operation. The

Figure 3. After tumor resection and osteotomy.

Figure 4. One day after operation.

M. P. Loxha-maxillofacial et al. / Open Journal of Stomatology 3 (2013) 344-346

346

OPEN ACCESS

Figure 5. Two weeks after operation.

Figure 6. Four months after surgery.

last one is important especially for the developing coun-

tries.

4. CONCLUSION

As carcinoma of the lower lip is a slow-growing, rela-

tively unaggressive cancer, it can be diagnosed and

reated easily and effectively. However, early treatment is

important because its mortality rate is 10% - 30%.

Early-stage lesions have very good prognoses. The re-

constructive techniques are various, depending on the

size and location of the loss of substance. In our case we

achieved good results using local flaps in one stage re-

construction of both upper and lower lip.

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