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Surgical Management of Malignant Tumors. อ. พญ. ทพญ. นุชดา ศรียารัณย ภาควิชาศัลยศาสตร์ช่องปาก คณะทันตแพทยศาสตร์ มหาวิทยาลัยเชียงใหม่. Etiology and predisposing factors. The exact cause of oral cancer is unknown Variations in incidence rates :

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surgical management of malignant tumors

Surgical Management of Malignant Tumors

อ. พญ. ทพญ. นุชดา ศรียารัณย


คณะทันตแพทยศาสตร์ มหาวิทยาลัยเชียงใหม่

etiology and predisposing factors
Etiology and predisposing factors

The exact cause of oral cancer is unknown

  • Variations in incidence rates :

differences in exposure to

carcinogenic initiators

risk factors
Risk factors
  • Genetic predisposition
  • Atmospheric pollution
  • Immunosuppression
  • Viruses
  • Fungal infection
  • Diet
  • Dental sepsis



  • 24% of all male deaths in developed world
  • 7% of all female deaths
  • Smoking is the cause of 45% of all cancer deaths
  • 95% of all lung cancer deaths
  • 85% of all oral cancer deaths
  • Carcinogens of tobacco


tobacco specific nitrosamines

  • Act locally on keratinocyte stem cells
  • Affecting DNA replication
  • Causing mutation
  • Pure ethanol is not carcinogenic
  • Nitrosamines and other impurities
  • Rising incidence of oral cancer linked to rising alcohol consumption
  • Ethanol increases mucous membrane permeability
  • Ethanolmetabolised to acetaldehyde locally by bacterial alcohol dehydrogenases and can damage cells – poor oral hygiene
  • Alcoholic liver disease reduces detoxification of carcinogens
  • High calorie value suppresses nutrition and leads to nutritional deficiencies
risk factors1
Risk factors
  • Genetic predisposition ?

- impaired capacity to metabolise


- DNA damage repair impaired

  • Atmospheric pollution

- polycyclic aromatic


risk factors2
Risk factors
  • Immunosuppression

- organ transplant patients – lip cancer

- no increased risk with AIDS of oral SCC

  • Viruses

-HPV 16 and 18

viral oncogene

deactivates p53

inhibit apoptosis

risk factors3
Risk factors
  • HPV and oral cancer
  • Prevalence 0-100 % in OSCC
  • But only 40% of head and neck SCC with p53 mutations had high risk HPV
  • Only 40% of HPV positive tumors showed p53 mutations
  • HPV infection is pobably an early event
  • Higher prevalence in younger patients
risk factors4
Risk factors
  • Other viruses

Herpes simplex

Epstein-Barr virus

Hepatitis virus

no clear evidence of involvement in oral cancer

risk factors5
Risk factors
  • Fungal infection

- candida albicans – potential to promote

nitrosation of dietary substrates

  • Diet

-Protective effect of antioxidants Vit A, C,

E and trace elements Zinc and selenium

  • Dental sepsis

- poor oral hygiene-socioeconomic status and

nitrosating enzyme in plaque

age and sex
Age and sex
  • older age
  • ~ 95% occur in over 40 Yrs
  • The average age at the time of Dx is about 60 Yrs
  • more frequent in males

Male : Female ~ 2 : 1

  • The Tongue is the most common site for oral cancer
  • Floor of mouth
histologic types
Histologic types
  • Carcinoma 96%
  • Sarcoma 4%
  • The most common type : squamous cell carcinoma
  • Major salivary gl. : malignant mixed tumor
  • Minor salivary gl. : adenoid cystic CA
  • Lymphoma
  • Metastatic tumors to oral cavity


  • Inspection : oral cavity, neck, pharynx
  • Palpation : neck , oral masses

1. Surgical biopsy

  • oral cavity : local anesthesia
  • Small lesions excisional biopsy
  • Incisional biopsy is recommended in all


surgical biopsy
Surgical biopsy
  • The biopsy : suspicious area of the lesion and some normal adjacent mucosa
  • Avoid area of necrosis or gross infection
2 toluidine blue test
2. Toluidine blue test
  • The suspicious area is paint with 1% aqueous solution of toluidine blue for 10 sec.
  • Rinsed with 1% solution of acetic acid
  • The toluidine blue binds to DNA present in the superficial cells and resists decoloration by acetic acid
toluidine blue test
Toluidine blue test
  • Dye binding is proportional to the amount of DNA present and the number and size of superficial nuclei in the tissues
  • false negatives
  • guide
3 fine needle aspiration biopsy
3. Fine needle aspiration biopsy
  • lumps in the neck (suspicious lymph nodes)
  • percutaneous puncture of the mass with a fine needle and aspiration of material for cytological examination
  • The node is fixed between finger and thumb
  • Puncture by a 21 or 23 gauge needle on a

10 ml syringe

  • A small amount of air is already in the syringe (2ml) before puncture
  • moving the needle around different parts of the node
  • the plunger is then released and the needle withdrawn through the skin
  • The tip of the needle must touch the slide
  • Smear slide
  • Wet fixed material:

an alcoholic ‘spray fixed’ immediately, 10 min

  • Thinner film : air dry
  • after the aspiration, aspirate 2ml of 95% ethanol as fixative into the same syringe
  • fast , almost painless, needs no specialised equipment and without complication
  • The technique depends on 2 aspects:

- successful puncture of the node

- transfer of cells and stroma onto slide

  • Frable and Young: 94.5% accuracy with head and neck lesions
  • may avoid the need for open biopsy
  • Risk of spreading malignant cells into the surrounding tissues

(Tumor implantation into the needle track, when large gauge needle has been used)

4 radiography
4. Radiography
  • Limited value
  • 50% of calcified component of bone must be lost before any radiographic change
  • Panthomography alveolar and antral involvement
  • lungs and skeleton
5 computerised tomography
5. Computerised tomography

Great benefit in head and neck

  • Primary tumor and lymph node metastasis
  • Value in the investigation of metastasis in the lungs, liver and skeleton
6 radionuclide studies
6. Radionuclide studies
  • Technetium pertechnetate bone scans
  • Not specific

(increased uptake : increased metabolic activity in the bone)

  • Detecting distant metastases
7 magnetic resonance imaging mri
7. Magnetic resonance imaging (MRI)
  • Highly contrasted image for soft tissue lesion
  • Bone is not imaged
  • only the marrow being directly visualized
8 ultrasound
8. Ultrasound

Noninvasive, readily available and cost effective

  • Abdominal ultrasound : liver metastases
  • intra-oral tumors : high degree of accuracy, demonstrating bone invasion (early stage)
  • Regional LN
precancerous lesion
Precancerous lesion
  • Leukoplakia
  • Erythroplakia
location of leukoplakia erythroplakia
Location of leukoplakia/erythroplakia

Occurrence probability of dysplasia

1. Buccal mucosa1. Floor of mouth

2. Mandibular vestibule2. Tongue

3. Maxillary gingiva3. Lower lip

4. Mandibular gingiva4. mandibular gingiva

5. Tongue5. Buccal mucosa

6. Floor of mouth6. Mandibular vestibule

7. Lower lip7. Maxillary gingiva



1. Mild Dysplasia

2. Moderate Dysplasia

3. Severe Dysplasia



  • Looking for etiology factors

- stop smoking immediately

  • non/mild dysplasia

- total excision

- F/U 3-6 mo. when non total excision

  • Moderate dysplasia

- total excision

- F/U 4-8 wk. when non total excision

  • Severe dysplasia

- total excision

- F/U every 4wk.


Moderate dysplasia


- total excision with 1 cm margin ,

extend in submucosa

- F/U every 4wk.



- total excision with 1 cm margin ,

extend in submucosa

- F/U every 4wk.

spread of tumor
Spread of tumor
  • Local extension
  • Lymphatic spread

- stepwise spread

  • Hematogenous spread
biology of metastasis
Biology of metastasis
  • SCC : most to regional LN

sometimes through blood

(lung, brain, bone)

biology of metastasis1
Biology of metastasis
  • Steps

1. Invasion through basement membrane,

between endothelial cell or blood vessel

(collagenase, heparanase, stromelysin)

2. Entrance into lymphatics or blood vessel

form tumor embolus

3. Survival of cancer cell in lymphatics or blood vessel

biology of metastasis2
Biology of metastasis

4. Escape from circulation into new tissue

(collagenase, heparanase, stromelysin)

5. Implantation in new tissue area with cloning

require : angiogenic factors, GF to recruit blood supply, stimulate self-replication, down regulate host cells, activate host cell (osteoclast)

incidence of ln metastases
Incidence of LN metastases

Depend on :

- size

- site

- histological type of primary


ln metastases
LN metastases
  • most commonly in the upper deep cervical and submandibular nodes on the same side of the primary tumor
  • lower deep cervical nodes : rare
  • Contralateral node metastases : rare
incidence of ln metastases1
Incidence of LN metastases

Site :

- more posterior lesion in the mouth

the more likely LN metastases

Retromolar trigone : 45%

Tongue : 35%

Floor of mouth = lower alveolus : 30%

buccal mucosa and hard palate, lower

lip : 10-15%

incidence of ln metastases2
Incidence of LN metastases



The better differentiated, the less metas.

verrucous CA : low

well diff. SCC : 26%

moderated diff. SCC :33%

poorly diff. SCC : 50%

diagnosis of ln metastases
Diagnosis of LN metastases
  • Clinical examination
  • Imaging
  • Cytology
  • Histology


- sensitivity similar to clinical exam.

sensitivity > 90%

Node above 1 cm suspicious of malinancy

diagnosis of ln metastases1
Diagnosis of LN metastases


- simple, relative cheap

- used to guide FNAB of impalpable nodes

diagnosis of ln metastases2
Diagnosis of LN metastases

Cytology (FNAB)

- useful confirmatory test

- accuracy is high

- false-negative results

open biopsy

lymphatic drainage
Lymphatic drainage

Superficial parotid LNsubmental LN

deep parotid LNsubmandibular LN

deep cervical LN

lymphatic drainage1
Lymphatic drainage
  • anterior floor of mouth, anterior alveolar ridge, lower lip submental triangle LN
  • Posterior floor of mouth, tongue, buccal mucosa, posterior alveolar ridge Submandibular LN
  • Cancer of tongue node of Stahr
  • retromolar trigone, tonsillar fossa, pharyngeal tongue jugulodigastric LN
lymphatic drainage2
Lymphatic drainage

- SCC Lung (multifocal)

Oral Lung (venous system)

- invasion into small vein

- drain to larger vein

- cancer emboli SVC

- heart

- pulmonary artery

classification and staging
Classification and staging

TNM classification

tnm classification
TNM classification
  • Pretreatment Clinical Classification(cTNM)

- clinical, radiological, other investigation

  • Postsurgical Histopathological Classification(pTNM)

- by surgical findings and the examination

of the therapeutically resected specimen

t primary tumor
T – Primary Tumor

TX Primary tumor cannot be assessed

TIS Pre-invasive carcinoma (carcinoma-in-situ)

T0 No evidence of primary tumor

T1 Tumor size ≤2 cm

T2 Tumor size > 2 but ≤ 4 cm

T3 Tumor size > 4 cm

T4 Massive tumor or Tumor invades adjacent

structures e.g. through cortical bone,

muscles (intrinsic) of tongue, muscle of

mastication, maxillary sinus, skin

n regional lymph nodes
N – Regional Lymph Nodes

NX Regional LNcannot be assessed

N0 Noregional LN metastasis

N1 single ipsilateral LN ≤ 3 cm

N2a ipsilateral LN >3 but ≤ 6 cm

N2b multiple ipsilateral LN ≤ 6 cm

N2c bilateral or contralateral LN ≤ 6 cm

N3 LN > 6 cm

m distant metastases
M – Distant Metastases

MX distant metastasis can not assessed

M0 no distant metastasis

M1 metastasis present

the stage grouping in uicc classification
The stage grouping in UICC classification

Stage 0 Tis N0 M0

Stage I T1 N0 M0

Stage II T2 N0 M0

Stage III T3 N0 M0

T1, T2, T3 N1 M0

Stage IV T4 N0, N1 M0

Any T N2, N3 M0

Any T Any N M1

histopathological grading g
Histopathological Grading (G)

GX Grade of differentiation cannot be


G1 Well differentiated

G2 Moderately differentiated

G3 Poorly differentiated

G4 Undifferentiated

the absence or presence of residual tumor after tx r
The absence or presence of residual tumor after Tx. (R)

RX Presence of residual tumor cannot be


R0 No residual tumor

R1 Microscopic residual tumor

R2 Macroscopic residual tumor

Basic aim of treatment

Eradication of tumor with satisfactory

physiological function

: mastication, phonation, facial expression

and an acceptable cosmetic appearance

treatment of oral cancer
Treatment of oral cancer
  • Surgery
  • Radiotherapy
  • Chemoradiotherapy
  • Surgery with adjuvant radiotherapy
Surgery : main of treatment

Primary site is resected,

cervical LN are removed

  • Radiotherapy

can be primary Tx. or combined with surgery

  • Chemotherapy

not suitable as primary Tx.

can be combined with surgery and radiation

team work
Team work
  • Surgeon
  • Radiotherapist
  • Medical oncologist
  • Pathologist
  • Supportive team (nurse, prosthetist, speech therapist, psychiatrist, etc.)


  • Site
  • Size (diameter, thickness , invasion)
  • Degree of histologic differentiation
  • Lymph node metastasis (Level, number)
  • Extranodal spread
  • Distant metastasis
ca of oral cavity management of primary tumor
CA of oral cavity management of primary tumor

Choice of treatment

factors in deciding

- site of origin

- stage of disease

- histology of the tumor

- medical condition and lifestyle

stage of disease
Stage of disease
  • Small lesion :

surgery without deformity (1cm margin)

  • Large mass with invasion of bone :

Surgery, low cure rates by radiotherapy

  • Lesions of intermediate stage

(larger T1, most T2, early exophytic T3) : controversial, similar survival rate (functional results and morbidity)

stage of disease1
Stage of disease

Advanced as to be unresectable :

Radiotherapy or chemotherapy

  • Previously irradiated tissue : relatively radioresistant because of limited blood supply : not advisable to re-treat

Multiple primary tumors or extensive

premalignant change :




poorly differentiated ~ higher incidence of lymphatic spread, worse prognosis

Verrucous CA in early stage (superficial

exophytic lesion : local excision

Adenoid cystic carcinoma of minor salivary

gland : nerve resection, nerve canal resection

medical condition and lifestyle
Medical condition and lifestyle
  • Age :

elderly, poor general condition, with advanced disease irradiation

  • Alcoholic patient, smoking : high risk of postradiation complication
principles of resection
Principles of resection
  • Palliative resection
  • Curative resection
palliative resection
Palliative resection

Aim improve quality of life

  • Reduction of the tumor size (when compression of vital structure)
  • Debulking : control of tumor with subsequent radiotherapy and/or chemotherapy
  • To relieve pain (direct excision or surgical decompession
curative resection
Curative resection
  • Remove tumor in one piece with margin of microscopically normal tissue

Frozen section

  • Management of regional lymph nodes
frozen section
Frozen section


  • Between surgery
  • Margin of resection tissue
  • residual
neck dissection
Neck dissection

‘Lymphatics and lymph node chain in the neck are contained in the cervical fascia and in fatty contents around the cervical fascia of the neck’

level i
Level I

submental LN (submental triangle)

laterally : two anterior bellies of digastric

inferior : hyoid bone

floor : mylohyoid

submandibular LN (digastric triangle)

superior : mandible

anterior : anterior belly of digastric

posterior : posterior belly of digastric

floor : mylohyoid, hyoglossus

level ii
Level II

Upper internal jugular nodes

caudal : carotid bifurcation or hyoid

dorsal : dorsal of sternoclidomastoid m.

anterior : stylohyoid muscle

level iii
Level III

Mid internal jugular nodes

cranial : hyoid and carotid bifurcation

caudal : omohyoid m.

anterior : sternohyoid m.

posterior : dorsal of sternocleidomastoid m.

level iv
Level IV

Lower internal jugular nodes

cranial : omohyoid m.

caudal : clavicular

anterior : sternohyoid m.

posterior : dorsal of sternocleidomastoid m.

level v
Level V

Spinal accessory, supraclavicular LN

and posterior triangle

anterior : dorsal of sternocleidomastoid m.

posterior : trapezius m.

inferior : clavicle

types of neck dissection
Types of neck dissection
  • Comprehensive neck dissection

- radical

  • Selective neck dissection

- functional sparing

Comprehensive neck dissection

Type Node level preserved

Radical ND I-V none

Modified RND 1 I-V SAN

Modified RND 2 I-V SAN, IJV

Modified RND 3 I-V SAN, IJV, SCM

standard radical neck dissection
Standard radical neck dissection

All LN are removed (level I-V)

superiorly : from the level of mandible

inferiorly : to the clavicle

postriorly : from the trapezius m.

anteriorly : to the midline

Sacrificing : sternocleidomastiod m., internal

jugular vein, spinal accessory n.

indications for radical neck dissection
Indications for radical neck dissection
  • N3 neck disease where accessory nerve not preservable
  • multiple positive LN involving accessory n. or internal jugular v.
  • Gross extranodal spread
  • Residual or recurrent disease after radiotherapy
contraindications for radical neck dissection
Contraindications for radical neck dissection
  • Distant metastases
  • Poor general condition or high risk for GA
  • Fixed LN with skin infiltration or ulceration
modified radical neck dissection
Modified radical neck dissection

1. MRND – I

preserves the accessory n.

2. MRND – II

preserves accessory n. and internal jugular vein


preserves accessory n.,

sternocleidomastoid m. and internal

jugular vein

indications for modified rnd
Indications for modified RND
  • N+ neck where all nodal levels require dissection
  • Where certained structures are involved by nodal metastases but others can be preserved.
  • To preserve function especially the accessory n.
  • Maintain IJV for microvascular anastomosis
selective neck dissection
Selective neck dissection
  • Some compartment or preserve structure

1. Submandibular triangle dissection

2. Suprahyoid ND (level I-II)

3. Supraomohyoid ND (level I, II, III)

indications for supraomohyoid nd
Indications for supraomohyoid ND
  • Oral cavity tumors
  • N0 neck
  • Small N+ disease
aims of neck dissection
Aims of neck dissection
  • Removed nodal metastases, manage disease in neck
  • Node sampling for accurate pathological staging to direct further Tx. of the neck
node disease and survival
Node disease and survival
  • Positive LN metastases are the single most important prognostic indicator for survival
  • Survival is decreased by up to 50%
oral cancer
Oral cancer
  • Tongue and floor of mouth

65% of all oral cancer

  • SCC : predominantly
The Tongue

20 –30% of oral cancer

  • Majority : middle third of lateral margin, extending onto the ventral aspect and floor of the mouth
  • 25% on posterior 1/3 of the tongue
  • 20% on anterior 1/3 of the tongue
  • 4% on the dorsum (associated with syphilitic glossitis)
The tongue


  • exophytic with ulceration,

superficial ulceration with infiltration

  • Endophytic tumor
The Tongue

Typical malignant ulcer:

  • Often several centimeters in diameter
  • Hard in consistency with heaped-up and

everted edges

  • Floor is granular, indurated and bleeds,

area of necrosis

the tongue
The tongue
  • difficulty with speech and swollowing
  • Pain : severe and constant, radiating to

the neck and ears

  • LN metastases : common (relatively early)
  • 12% may present with no symptoms other

than a lump in the neck

the tongue1
The Tongue


  • Small lesion : intraoral excision

Excision of less than 1/3: no reconstruction

  • Exceeding 2 cm : hemiglossectomy
the tongue2
The Tongue
  • Extensive tongue lesion involve floor of mouth and alveolus :

lip split and mandibulotomy

  • Tumors reach the alveolus : rim resection of the mandible, reconstruction with distant flap
  • not exceed 2/3 of tongue : radial forearm free flap with microvascular anastomosis
the tongue3
The Tongue
  • Large volume defect, total glossectomy, deeply infiltrating tumor :

resection extends to hyoid bone,

pectoralis major muscle flap

  • When possible at least one hypoglossal n. should be preserved
the floor of the mouth
The floor of the mouth
  • second most common site for oral cancer
  • Most : anterior of the floor of mouth to

one side of the midline

  • Indurated mass
  • Early stage : tongue and lingual aspect of the mandible become involved
the floor of the mouth1
The floor of the mouth
  • Early slurring of the speech
  • Lymphatic metastasis is less common, usually to submandibular and jugulodigastric nodes and may be bilateral
  • Associated with preexisting leukoplakia more commonly
floor of the mouth
Floor of the mouth


  • small tumor : simple excision (1 cm margin)
  • involve the under surface of tongue and lower alveolus :

surgical excision partial glossectomy

and marginal resection of mandible,

reconstructed with local or distant flap

the gingiva and alveolar ridge
The Gingiva and alveolar ridge
  • Predominantly in the premolar and molar regions
  • proliferative tissue at the gingival margins or superficial gingival ulceration
  • Hx. of tooth extraction with subsequent failure of the socket to heal or sudden difficulty in wearing dentures
  • Edentulous alveolar ridge : indolent superficial ulceration often adjacent to leukoplakia
the gingiva and alveolar ridge1
The Gingiva and alveolar ridge

DDx :

  • apical or periodontal abscess
  • Pyogenic granuloma
  • Peripheral giant cell granuloma
  • Pregnancy granuloma
  • Polypoid
  • Sessile fibroepithelial lesion
  • Denture granuloma
the gingiva and alveolar ridge2
The Gingiva and alveolar ridge
  • Invasion of the underlying bone 50% of cases (important consequences for treatment)
  • Regional nodal metastasis is common


lower alveolus
Lower alveolus

Modality of choice : surgery

  • Marginal resection
  • Extensive invasion :

continuity resection and reconstruct

with free corticocancellous graft

(iliac, rib) or microvascular tissue


the buccal mucosa
The buccal mucosa
  • SCC mostly arise at the commissure or along the occlusal plane to the retromolar area
  • majority : situated posteriorly
  • Exophytic, ulcero-infiltrative and verrucous type
  • Sometimes presenting with trismus

(deep neoplastic infiltration into the

buccinator muscle)

the buccal mucosa1
The buccal mucosa
  • LN metastasis :


parotid and lateral pharyngeal nodes

buccal mucosa
Buccal mucosa


  • Lesion confined to buccal mucosa :

wide excision include buccinator m. and

split thickness skin graft

  • Small defects up to 3 x 5 cm :

excision and closure with buccal fat pad

  • More extensive lesions :

reconstruction with free radial fore

arm flap, temporalis muscle flap

the hard palate maxillary alveolar ridge and floor of antrum
The hard palate, maxillary alveolar ridge and floor of antrum

Presenting symptom :

  • Complaint of painful or ill-fitting denture
  • CA in the floor of maxillary antrum often present as palatal tumors present with dental symptoms

early symptoms are non specific and mimic chronic sinusitis

the hard palate maxillary alveolar ridge and floor of antrum1
The hard palate, maxillary alveolar ridge and floor of antrum

symptom :

  • painless loose teeth
  • failure of the sockets to heal after extraction
  • swelling in the mucogingival fold
  • pain, swelling or numbness of the face
  • Later symptoms : nasal obstruction, discharge or bleeding oro-antral fistula
the hard palate maxillary alveolar ridge and floor of antrum2
The hard palate, maxillary alveolar ridge and floor of antrum

symptom :

  • Occasionally localised or referred pain in the premolar or molar teeth : early infiltration of the posterior superior dental n.
  • Trismus : tumors extend backwards into the pterygoid region
the hard palate maxillary alveolar ridge and floor of antrum3
The hard palate, maxillary alveolar ridge and floor of antrum
  • LN metastasis from CA of the palate and floor of the antrum : late, poor prognosis
  • Initially to submandibular nodes and then to the deep cervical chain
hard palate and upper alveolus and maxillary antrum
Hard palate and upper alveolus andmaxillary antrum
  • Tumor of minor salivary gl. are more common
  • SCC arise from maxillary antrum


  • Involve bone : surgery
  • Radiotherapy alone for small early superficial tumor
hard palate and upper alveolus and maxillary antrum1
Hard palate and upper alveolus and maxillary antrum
  • Tumor in hard palate, upper alveolus, floor of antrum : partial maxillectomy
  • More extensive tumor confined to maxilla : total maxillectomy
  • Exposed through a Weber-Fergusson incision
hard palate and upper alveolus and maxillary antrum2
Hard palate and upper alveolus and maxillary antrum
  • Defect : reconstruction or obturator prosthesis
  • Reconstruction : local flap or free flap
  • Small posterior defect : buccal fat pad or masseter muscle flap
carcinoma of the lip
Carcinoma of the lip
  • SCC
  • Lower lip > upper lip
  • Greater exposure of lower lip to sunlight
  • Ulcer, keratin crust covers ulcer
  • Rest of lip vermillion may show actinic change
carcinoma of the lip1
Carcinoma of the lip
  • Up to 1/3 of lower lip can be removed
  • Up to 1/4 of upper lip can be removed

V or W shaped excision with

primary closure (up to 2 cm diameter)

  • large central defect of lower lip

Step ladder approach of Johanson

  • Abbe or Estlander plastic
retromolar trigone
Retromolar trigone
  • Anterior surface of ascending ramus
  • Tumor invade the ascending ramus
  • Spread to pterygomandibular space
retromolar trigone1
Retromolar trigone
  • Surgery : lip split and mandibulotomy
  • Small defect : reconstructed with masseter or temporalis muscle flap
  • Larger defect : free flap