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25 Lip Reconstruction withLocal Flaps
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25.6.1 Defects ofuptoOne-Third oftheLip
Width
In the vast majority of cases, up to one-third of the lower lip
can be removed by simple wedge excision (Fig.25.6) and the
resultant defect is then closed primarily in layers. In elderly
patients, with greater tissue laxity, this is never a problem
(Fig.25.7).
In a minority of cases, the wedge may have to be modied
by extending the incision unilaterally or bilaterally along the
labiomental fold and excising skin crescents. This technique
aids in advancing the remaining lip centrally. When the crescents are bilaterally extended as far as the mandibular border,
accompanied by mucosal release incisions, the technique is
known as the Schuchardt procedure.
25.6.2 Defects ofOne-Third toOne-Half
oftheLip Width
Rarely, in some elderly patients with lax tissues, it may be
possible to primarily close wedge excisions greater than onethird of the width of the lower lip. In the vast majority of
cases, however, reconstruction of between one-third and
one-half of the lower lip is best performed by using residual
lip tissues, or lip sharing. Such techniques preserve lip function and have satisfactory aesthetic results, but they can
cause microstomia. Arguably the best lip-sharing technique
is the Karapandzic procedure [11]. This elegant rotation-
advancement technique can be used on both lateral and central lower lip defects, and sometimes upper lip defects. A
unilateral ap can sufce for lateral defects, but bilateral
aps are required for central defects.
The Karapandzic technique (Figs.25.8, 25.9, and 25.10)
creates paired full-thickness mucomusculocutaneous lip
aps supplied by branches of the facial artery, and it preserves the sensory and motor nerves to the lip segments. It is
crucial that the skin incisions are made at a distance from the
lip margin equivalent to the height of the lip defect, especially at the commissures, in order to restore normal lip
height. It should be noted that the superior incisions are normally placed lateral to the nasolabial creases for this purpose.
The mucosal incisions are parallel to the skin incisions but
are much shorter, usually about 2cm on each side. For central lower lip defects, the lip depressor muscles must be completely divided bilaterally to allow the aps to move medially.
For large defects, the superior incisions are deepened through
skin, fat, and the supercial layer of facial muscles, preserv-
1
3
Fig. 25.6 Defects of up to one-third of the lower lip can be closed with various wedge techniques (1–3) or bilateral advancement aps (4)
2
4
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R. Chalmers and O. A. Ahmed
ab
Fig. 25.7 (a) Modied wedge excision of lower lip squamous cell carcinoma (SCC) in an elderly patient. (b) Closure of wedge excision
1
2
Fig. 25.8 Karapandzic technique: (1) Mark out the excision margin
and ap. The ap should be the same height as the lip at all points
around the ap. (2) After full-thickness excision (including mucosa),
mobilise the crescenteric aps at equidistance from the free lip margin
ing only the buccinator and orbicularis oris. During this
manoeuvre, the delicate vessels and nerves to the lip must be
carefully preserved. It is important to note that the nerves
enter the aps radially. After ap rotation, the supercial
muscle layer should be reattached to the orbicularis. For relatively small defects, It is possible to rotate the aps without
necessarily dividing the supercial facial muscles; instead,
the muscles in the superior incisions can simply be teased
until the aps are free to advance—the “cut as you go”
approach. After ap rotation, the wounds are closed in layers
from within outwards, paying careful attention to the muscle
layer. The functional results of this reconstruction are very
good, but microstomia is inevitable with large defects.
2
and full thickness for 2cm from the postexcisional defect. With scissors, the blood and nerve supply around the commissure is preserved.
(3) Tension-free rotation of the aps recreates the lower lip and
vermilion
3
Defects of the lower lip not involving the commissure can
be reconstructed by a “reversed” Abbe-Sabattini ap from
the upper lip (Fig.25.11). To avoid excessive shortening of
the upper lip and to evenly distribute tissues between the
upper and lower lips, the ap should be half the width of the
lip defect. These aps do lead to an insensate, adynamic segment of lip; though a degree of reinnervation eventually
occurs, they are better suited for upper lip reconstruction.
Their main advantage is that they do not blunt the oral
commissures.
ab
cd
25 Lip Reconstruction withLocal Flaps
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Fig. 25.9 (a) Markings for resection of SCC of the right side of the lower lip, and design of a left-sided Karapandzic ap. (b) Karapandzic ap
assessed for adequate mobilisation. (c) Karapandzic ap inset. (d) Good aesthetic and functional result
25.6.3 Defects Greater Than One-Half
oftheLip Width
to use adjacent cheek tissues. Such reconstructions can
achieve satisfactory aesthetic results, but function is always
suboptimal.
For larger defects, lip-sharing procedures such as the
Karapandzic lip reconstruction can be used when tissue laxity allows. This technique preserves lip function, but a degree
of microstomia will inevitably occur and secondary revision
is usually required. When the lip defect is greater than three
quarters, there will usually be insufcient lip tissue for a satisfactory reconstruction. In such cases, the next best option is
The Bernard-von Burow procedure (Fig. 25.12) recon-
structs the lower lip by medially advancing the cheeks.
Cheek advancement is facilitated by the excision of fullthickness triangles of cheek tissue above and below the
defect at the nasolabial fold. The width of the triangular excision is equal to the width of the defect. When both cheeks are
advanced, the base of each triangle is half the width of the lip
238
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Fig. 25.10 (a) SCC of central lower lip and design of bilateral Karapandzic aps. Note that the width of the aps is equivalent to or greater than
the height of the lip defect throughout. (b) Bilateral Karapandzic aps inset
R. Chalmers and O. A. Ahmed
2
1
Fig. 25.11 Reversed Abbe-Sabattini ap to for a lesion of one-third of
the lower lip. (1) Lesion marked out for excision. (2) Flap design. (3)
Full-thickness incision of the upper lip ap, with the medial free margin
4
5
3
of the upper lip inserted in the lateral margin of the lower lip excision.
(4) Donor site closure. (5) The pedicle can be divided and inset at
14days
2
1
3
45
Fig. 25.12 Modied Bernard-von Burow technique for up to total lip
reconstruction. (1) Lesion marked out and ap marked out with two
superior and two inferior Burow’s triangles. (2) Burow’s triangles are
excised into subcutaneous tissue lateral to nasolabial folds. (3) Around
the labiomental fold, Burow’s triangles are excised to allow medial
rotation of the lower cheek aps. (4) Medial advancement of the cheek
aps. (5) 3-layered closure of the midline with a mucosal ap reconstruction of the vermilion
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239
1
Fig. 25.13 Unilateral Freeman modication of the Bernard-von
Burow procedure. (1) Mark out excision margin and lateral nasolabial
triangle. (2) Advance lower lip into defect. (3) Excision of tissue super-
3
defect. Tongue aps reconstruct the vermilion. Webster’s
modication of this technique mobilises cheek mucosa to
reconstruct the vermilion.
The Freeman modication of the Bernard-von Burow
operation is probably the best current cheek advancement
technique (Fig.25.13). Freeman converted the lower incision
of the Bernard-von Burow operation from a horizontal one to
a curved one, following the labiomental crease. Only skin
and fat are removed in the triangular excisions, in contrast to
2
4
cial to the muscle will allow medial advancement, whilst incision of
the muscle lateral to the commissure will facilitate a
commissuroplasty
the full-thickness tissue excision of the older procedure.
Bilateral cheek advancements can be used for total lower lip
reconstruction, but there can be signicant facial scarring.
For the best function, it is important to reconstruct the orbicularis muscle.
An alternative for total or subtotal lip reconstruction is to
combine unilateral cheek advancement with a contralateral
Karapandzic aps (Fig.25.14).
240
a
b
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c
R. Chalmers and O. A. Ahmed
Fig. 25.14 Combined unilateral cheek advancement with a contralateral Karapandzic ap. (a) Subtotal defect of the lower lip, with left cheek
advancement performed and right Karapandzic ap designed. (b) Intraoperative appearance. (c) Immediate postoperative appearance
References
1. Sushruta. An English translation of the Sushruta Samhita, based on
original Sanskrit text. Edited and published by Kaviraj Kunja Lal
Bhishagratna.
2. Dieffenbach JF.Chirurgische Erfahrungen Series 3. 1834;4:101.
3. Sabattini P.Cenno storico dell’origene e progressi della rinoplastica
e cheiloplastica. Bologna: Bella Arti; 1938.
4. Abbe R.A new plastic operation for the relief of deformity due to
double harelip. Med Records N Y. 1898;53:477.
5. Estlander JA.En method att fran den ena lappen fylla substansforluster i den andran och i kinden. Nord Med Archiv. 1872;4:1–12.
6. von Burow CA.Beschreibung einer neuen Trasplantations-Method
(Method der seitlichen Dreiecke) zum Wiederersatz verlorengegangener Teile des Gesichts. Berlin, Germany: Nauk; 1855.
7. Bernard C. Cancer de la lèvre inférieure: restauration à l’aide de
lambeaux quadrilataires-latéreaux. Querison. 1852;5:162–4.
8. Freeman BS.Myoplastic modication of the Bernard cheiloplasty.
Plast Reconstr Surg. 1958;21:453–60.
9. Webster RC, Coffey RJ, Kelleher RE.Total and partial reconstruction of the lower lip with innervated muscle-bearing aps. Plast
Reconstr Surg. 1960;25:360.
10. McGregor IA. Reconstruction of the lower lip. Br J Plast Surg.
1983;36:40–7.
11. Karapandzic M.Reconstruction of lip defects by local arterial ap.
Br J Plast Surg. 1974;27:93–7.
12. Harii K, Ohmori K, Ohmori S.Utilization of free composite tissue
transfer by microvascular anastomoses for the repair of burn deformities. Burns. 1975;1:237–44.
13. Webster JP.Crescentic peri-alar cheek excision for upper lip ap
advancement with a short history of upper lip repair. Plast Reconstr
Surg. 1955;16:434.
Part X
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Oral Cavity Surgery
Transoral Partial Glossectomy
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ArpanTahim andZaidSadiq
26
26.1 Introduction
Transoral partial glossectomy is a key intervention in the surgical management of tongue cancer. Although there is considerable overlap in terminology, the term partial glossectomy
typically refers to a procedure in which no more than onethird of the tongue is removed. When between a third to half
of tongue tissue is removed, the term hemiglossectomy is
more appropriate; subtotal glossectomy and total glossec-
tomy refer to the removal of even greater proportions of the
tongue. For many early, small cancers, a through-the-mouth
(transoral) approach is sufcient, but depending on lesion
site and size, greater access can be obtained via different oral
and extraoral approaches such as a lip split or mandibulotomy, or via the neck. This chapter discusses transoral partial
glossectomy, exploring its indications, reviewing established
and newer surgical techniques, and discussing postoperative
functional recovery.
26.2 Indications
The tongue has an embryologically and anatomically complex
structure. It begins to develop in the fourth week of life from the
oor of the primitive pharynx. Its anterior two thirds arises with
the fusion, in the midline, of protrusions from the rst pharyngeal arches. The posterior portion arises from the third and
fourth pharyngeal arches. These embryonic origins go some
way to explain its vascular and nerve supply. It is important to
note that it is tumours affecting the anterior and anterior lateral
tongue that are largely amenable to treatment via transoral
approaches, as they are appropriately accessible (Fig.26.1).
A. Tahim (*)
Department of Head and Neck Surgery, University College London
Hospital, London, UK
e-mail: arpan.tahim.17@ucl.ac.uk; a.tahim@nhs.net
Z. Sadiq
Oral and Maxillofacial Surgery, Queen Victoria Hospital,
East Grinstead, UK
e-mail: zaidsadiq@nhs.net
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_26
243
244
or longitudinal
Anterior mandible
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A. Tahim and Z. Sadiq
a b
Fig. 26.1 (a) An early left lateral tongue squamous cell carcinoma. (b) An anterior tongue squamous cell carcinoma affecting the entirety of the
right tongue
Fig. 26.2 The intrinsic and
extrinsic tongue musculature
Styloglossus
Palatoglossus
Superi
muscles
Ver ticalis and
transversus muscles
Inferior longitudinal
muscles
Posterior mandible
(cut)
Genioglossus (cut
anteriorly)
Hyoglossus (cut)
The tongue consists of squamous epithelium overlying a
complicated, dynamic muscular complex suspended from the
lingual aspect of the mandible, the hyoid bone, and the styloid
Hyoid bone
process. There are four pairs of intrinsic muscles, with no
bony origins (Fig. 26.2). Inferior and superior longitudinal
muscles work to move the tip of the tongue up and down.
Submandi
ght arch
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Sandwiched between these muscles lie the transversus muscle, which narrows and lengthens the tongue, and the verticalis
muscle, which attens the tongue. Extrinsic tongue muscles
include the genioglossus, which protrudes the tongue, and the
hyoglossus, which depresses it. The styloglossus and palatoglossus muscles elevate and retract the tongue.
The tongue has a rich vascular system, supplied predominantly from lingual arteries. The lingual artery passes medial
to the hypoglossal nerve, between the hyoglossus and genioglossus. It then travels submucosally with accompanying
veins and the lingual nerve on the undersurface of the anterior tongue towards the tongue tip. The lingual nerve runs
anteriorly along the inner aspect of the mandible, typically
close to the lower third molars (Fig. 26.3). There is wide
variation in its described course, but recent cadaveric studies
suggest that it lies lateral to the submandibular duct at the
distal molars. In the region of the second molar, it changes
course to move medially into the oor of the mouth and
crosses inferior to the submandibular duct. It then moves
upwards and anteriorly, now medial to the submandibular
duct, into the body of the anterior tongue, giving off several
smaller terminal branches [1].
Squamous cell carcinoma is by far the commonest type of
tongue cancer. It can present at the lateral border in approximately 80% of cases, the dorsal surface in 6%, the ventral
surface in 5%, and the posterior/base of the tongue in up to
8% [2, 3]. Lesions on the ventral surface of the tongue may
be difcult to differentiate from oor-of-mouth tumours,
especially in the glossotonsillar fossa. When planning surgery, this differentiation is highly relevant and can impact
speech and swallowing after resective surgery. Regardless of
the location, appropriate clinical visualization of any lesion
is vital, requiring good lighting and an unobstructed view.
Although straightforward in anterior tongue lesions, lesions
affecting the posterior third of the tongue may require exible nasendoscopic assessment.
As with most oral cavity cancer, the key risk factors are
smoking and high alcohol intake, but viral aetiologies are
increasingly being implicated, particularly in the posterior
tongue of younger patients. In keeping with oncological
principles, tongue cancers should be staged based on size
and depth of invasion, the presence of neck metastasis, and
evidence of distant spread, with management discussed in a
multidisciplinary team setting.
Typical staging involves clinical assessment, with xity
of the tongue or ear pain strongly suggestive of advanced
local disease. Further evaluation can be done with three
dimensional cross-sectional imaging, although intraoral
ultrasound scanning is increasingly seen as a useful adjunct
to characterize local tumour characteristics such as depth of
invasion [4]. Nodal spread is best evaluated using ultrasonography, with particular attention paid to the lymph node
basins where anterior tongue tumours most commonly
spread: levels IIA (37.1%), III (20.9%), and 1B (13.5%) [5].
Outline of overlying
mandible as seen
from the right side
Styloglossus
Lingual nerve
bular
gland (cut)
Hyoid bone
Fig. 26.3 The relationship of the right lingual nerve, Wharton’s duct,
and the overlying oral cavity landscape. The nerve lies lateral to the
duct in the region of the distal molars before passing inferior to it in the
Tongue surface
Te rminal branches
of the lingual nerve
Overlying dentition
in the lower ri
Submandibular duct
(opening into the
floor of mouth)
Hyoglossus
Geniohyoid
region of the lower second molars, prior to entering the body of the
anterior tongue
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