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Fig. 32.5 Lip markings for
chin contour incision and
methylene blue points for
reapproximation
Fig. 32.6 Note the chevron
incision at lip margin
O. Breik et al.
Fig. 32.7 Incisions
completed through lip split
tion of tooth roots determined on the OPG.If a tooth at the
site needs extraction, then the osteotomy can be more easily
performed through the extraction socket. Avoid a midline
osteotomy where possible, as this will necessitate division of
the genial muscles and the anterior belly of the digastric. If
a
32 Access Procedures: Visor Flap, Lip Split, Mandibulotomy, andLingual Release
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Fig. 32.8 Incisions made
down to mandible, with
subperiosteal dissection
enough for plates to be
applied
Fig. 32.9 (a) Pre-bent plates
with monocortical osteotomy
performed. (b) Plates secured
311
b
Fig. 32.10 Completed
osteotomy
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O. Breik et al.
then performed with a reciprocating saw to complete the
osteotomy (Fig. 32.10). Once the osteotomy is complete,
care needs to be taken to perform the lingual/medial incisions before separation of the osteotomised segments, to
avoid mucosal tearing. The surgeon can then use a nger to
isolate the mylohyoid muscle before transecting the muscle
(Fig.32.11). Access is then gained, and the resection can be
completed as planned (Figs.32.12 and 32.13).
Closure of the lip split mandibulotomy proceeds in a stepwise fashion. If microvascular free tissue transfer is needed,
then the posterior inset is performed rst, followed by plating of the mandible with the pre-bent plates while the patient
is in occlusion (Fig. 32.14), followed by layered closure:
mucosa, muscle, subdermis, skin. Reapproximation of the
Fig. 32.11 Once the
osteotomy is completed, the
operator can use a nger to
isolate the mylohyoid muscle
before transection of the
muscle
orbicularis oris is vital to avoid notching of the lip, preserve
perioral function, and reduce the chance of wound dehiscence (Fig.32.15).
32.4.3 Lingual Release
A standard visor ap is raised as described above and is carried just over the lower border of the mandible. The neck
dissections are then performed as planned, subsequently
enabling clear visualisation of the mylohyoid muscle at the
time of resection. Depending on the location of the tumour,
the oor of mouth release is modied. If the lesion is conned to the mobile oral tongue or has minimal extension
Fig. 32.12 Retracted lip
split, demonstrating access to
the posterolateral tongue
tumour. Black arrow shows
the tumour, yellow arrow
shows the retracted mandible,
green arrow shows the
planned anterior resection
margin
Fig. 32.13 Completed
resection with lip split access
32 Access Procedures: Visor Flap, Lip Split, Mandibulotomy, andLingual Release
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Fig. 32.14 Re-plated
mandibulotomy. Yellow arrow
demonstrates the radial
forearm free ap inset prior to
plating
313
Fig. 32.15 Completed lip
split closure
onto the oor of the mouth, a paralingual incision can be
made in the lingual sulcus, allowing enough lateral oor
mucosa for closure, but still allowing complete mobilisation
of the tongue and the remaining oor of the mouth. For a
more posterior lesion, the paralingual incision can extend
into the glossotonsillar/glossopalatine fold bilaterally and
down the lateral pharyngeal wall on the involved side for
additional exposure. Such a posterior extension necessitates
transection of the lingual nerve; so, if possible, this should
only be performed on the involved side. The mandible is then
closed into occlusion with a retractor, and the anterior belly
of the digastric and genial muscles are divided and separated
from the symphysis of the mandible, allowing delivery of the
tongue into the neck.
If the lesion extends to the alveolar mucosa, then the lateral incision is made intraorally and the medial dissection
proceeds in the subperiosteal plane along the lingual aspect
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O. Breik et al.
Fig. 32.16 (a) Access to
tongue via lingual release. (b)
Lingual release gives
adequate access for resection
of subtotal and total
glossectomy. (c) Subtotal
glossectomy specimen
showing deeply inltrative
squamous cell carcinoma
within the left posterolateral
tongue and glossotonsillar
sulcus, with oropharyngeal
extension. Visor approach
with lingual release allowed
good access for resection with
good surgical margins
a
b
c
32 Access Procedures: Visor Flap, Lip Split, Mandibulotomy, andLingual Release
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of the mandible, down through the mylohyoid attachment to
the mandible into the neck. The contralateral oor release
can be performed paralingually to allow lingual release into
the neck for resection (Fig.32.16).
For the edentulous patient, the incision should be on the
crest of the mandible. This avoids a sulcular incision, which
would compromise the lingual sulcus depth necessary for
future prosthetic rehabilitation. If teeth are extracted, the
incision is placed through the lingual gingival margin, and
extraction and alveoloplasty are performed as needed.
Adequate closure of the lingual release involves meticulous reattachment of the suprahyoid muscles to the anterior
mandible. Closure starts with inset of a microvascular free
ap and subsequently closure of the oor of the mouth or
the alveolar crest. Once the oor of the mouth is closed, the
suprahyoid muscles are resuspended. This may be performed by repairing the divided anterior belly of the digastric with long-lasting resorbable sutures such as
polydioxanone, or by suturing the muscle through holes created in the lower border of the mandibular symphysis. The
neck incision is closed in the standard way by closure of the
platysma, then the skin.
32.4.4 Chin Point Osteotomy
This osteotomy is performed with a standard visor ap rst
to the lower border of the mandible. Several techniques have
been described for the chin point osteotomy, such as a sagittal lingual plate osteotomy described by Merrick etal. [5].
Our preference is to perform a bicortical chin point osteot-
omy similar to that described by Lalabekyan et al. [6].
Subperiosteal dissection between mental foramina is then
performed to provide access to the symphysis of the mandible. The chin point osteotomy is designed as a box osteotomy between mental foramina and below the level of the
tooth apices superiorly. Once planned, a monocortical osteotomy is performed. The plating options include using two
‘L’-shaped plates bent to shape, or two four-hole plates along
the lower borders bilaterally, and a two-hole plate
superiorly.
The bicortical osteotomy is then performed to allow
mobilisation of the chin point inferiorly (Fig. 32.17). The
oor-of-mouth release is then performed as described above
for the lingual release approach. This technique allows the
chin to be pedicled inferiorly without disrupting the hyomandibular musculature.
Closure is the same as with the lingual release, with the
addition of plating of the chin anteriorly (Fig.32.18).
32.4.5 Cheek Flap
This access procedure involves the same lip split incision as
with a lip split mandibulotomy but without the mandibulotomy. This technique can be used in cases where a mandibulotomy may compromise resection margins such as with a
large buccal mucosal tumour. Once the lip split incision is
made, the cheek ap can be raised in the subcutaneous fat
plane deep to the masseter muscle as far as required to clear
the posterior aspect of the tumour. Subsequently, the tumour
can be resected in addition to either a partial maxillectomy
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Fig. 32.17 Access with chin
point osteotomy. (a)
Attachment of the anterior
belly of the digastric is
maintained. (b and c)
Completed chin point
osteotomy, demonstrating
good access to the tongue.
Access is not as good as a
mandibulotomy, but similar to
a lingual release
O. Breik et al.
a
b
c
32 Access Procedures: Visor Flap, Lip Split, Mandibulotomy, andLingual Release
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Fig. 32.18 Visor approach
with chin point osteotomy,
with plates in situ. Yellow
arrow demonstrates preserved
attachment of the anterior
bellies of the digastric
abc
317
Fig. 32.19 Cheek ap raised for excision of a large buccal mucosal
SCC in a patient with limited mouth opening due to betel-nut-induced
submucosal brosis. (a) Raising the cheek ap after the lip split incision. Green arrow demonstrating the anterior aspect of the tumour
being reected. Yellow arrow demonstrates that mandibular continuity
and/or a marginal mandibulectomy as required (Fig.32.19).
The mental nerve has to be sacriced in this approach. This
technique also provides good access for insetting a ap.
Closure is the same as with a lip split approach as discussed
earlier.
32.5 Postoperative Care
Standard postoperative care is performed, with no signicant
modications for those who have undergone an access procedure. The scar for a lip split should ideally be coated in
parafn and protected from desiccation during the initial
healing process. No other precautions are necessary. Once
the patient is decannulated, it is good practice to perform a
baseline OPG if a mandibulotomy or a chin point osteotomy
has been performed, to evaluate xation and conrm that no
inadvertent mandibular fractures have occurred. If a
is preserved. (b) Demonstrating the tumour being reected after a partial maxillectomy and marginal mandibulectomy for complete excision.
(c) Demonstrating the defect after resection with the cheek ap raised
prior to microvascular free ap inset
mandibulotomy has been performed, a soft, non-chew diet
must be continued for 6 weeks after surgery to facilitate
osseous union before returning to normal oral function.
References
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oropharyngeal cancer. J Surg Oncol. 1976;8:433–6.
2. Devine JC, Rogers SN, McNally D, Brown JS, Vaughan ED. A
comparison of aesthetic, functional and patient subjective outcomes following lip-split mandibulotomy and mandibular lingual releasing access procedures. Int J Oral Maxillofac Surg.
2001;30:199–204.
3. Cilento BW, Izzard M, Weymuller EA, Futran N.Comparison of
approaches for oral cavity cancer resection: lip-split versus visor
ap. Otolaryngol Head Neck Surg. 2007;137:428–32.
4. Myers LL, Sumer BD, Truelson JM, Ahn C, Leach JL.Resection
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5. Merrick GD, Morrison RW, Gallagher JR, Devine JC, Farrow
A. Pedicled genial osteotomy modication of the mandibular
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10. Ward GE, Robben JO.A composite operation for radical neck dissection and removal of cancer of the mouth. Cancer. 1951;4:98–109.
11. Stanley RB.Mandibular lingual releasing approach to oral and oropharyngeal carcinomas. Laryngoscope. 1984;94:596–600.
12. Rapidis AD, Valsamis S, Anterriotis DA, Skouteris CA.Functional
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Part XIII
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Oropharynx
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