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Fig. 6 Growth on the left lateral border with good mouth
opening, a good candidate for peroral resection
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Fig. 8 Posteriorly based growth on the left lateral border
of the tongue: the posterior margin is not visible adequately. A cheek ap approach may be required in such
cases
Fig. 7 Growth on the dorsum of the tongue, such lesions
entail anterior second/third glossectomy
2.1 Types ofGlossectomies
This was proposed by Ansarin and colleagues in
2019 [23]:
• Type I glossectomy (mucosectomy)—The
mucosa and submucosa are included up to the
intrinsic muscle bres of the tongue. The deep
resection margin should include a thin layer of
the intrinsic muscles because of a possible
invasion of the submucosa. Generally, the
wound is left to heal by secondary intention,
although the defect may be partially closed
primarily:
– Indication: Precancerous, supercial suspi-
cious lesions, limited to the epithelium of
the tongue without previous biopsy
• Type II glossectomy (partial glossectomy)—It
includes the lesion and adjacent normal
mucosa, submucosa and the intrinsic muscles
up to the surface of the extrinsic muscles
(when the directions of the muscle bres
change), with appropriate safety margins:
– Lesions inltrating the submucosa and
supercially into intrinsic muscles, but not
extrinsic muscles, or inltration less than
10mm deep
• Type IIIa glossectomy (hemiglossectomy)—
The specimen includes the mucosa, submucosa and intrinsic and extrinsic muscles
ipsilateral to the lesion. The mucosa is resected
up to the healthy tissue with appropriate safety
margins (at least 1.5 cm); the lingual artery
must be ligated and removed en bloc with the
lingual and hypoglossal nerves, in the speci-
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N. M. Nagarkar et al.
men of the primary tumour and neck nodes.
The base of the ipsilateral tongue is preserved.
The tip of the tongue can be preserved or not:
– Lesions inltrating the intrinsic and mini-
mally extrinsic muscles or inltration
greater than 10mm but conned within the
ipsilateral tongue
• Type IIIb glossectomy (compartmental hemiglossectomy)—The specimen includes the
mucosa, submucosa, intrinsic and extrinsic
muscles ipsilateral to the lesion, genioglossus,
hyoglossus and styloglossus muscles and the
inferior portion of the palatoglossus muscle.
Medially, the midline raphe is included in the
resection. The lingual nerve is resected as far
cranially as possible. The hypoglossal nerve is
removed after the ansa, the lingual artery and
vein are ligated in proximity to the horn of the
hyoid bone and removed en bloc with specimen and neck nodes:
– Lesions massively inltrating the intrinsic
and extrinsic muscles but conned to the
ipsilateral tongue
• Type IVa glossectomy (subtotal glossectomy)—This is an anterior subtotal glossectomy with preservation of both sides of the
base of the tongue, posterior hyoglossus
muscle and hypoglossal and lingual nerves,
from the less involved side:
– Lesions that arise in the anterior portion of
the mobile tongue and exceed the hemilingual area of origin involving the contralateral genioglossus muscle but limited to
mobile tongue
• Type IVb (near-total glossectomy)—Type IVa
glossectomy with extension to the ipsilateral
base of the tongue. The following contralateral structures are preserved: hyoglossus and
styloglossus muscles, hypoglossal and lingual
nerves and lingual artery (functional unit of
the base of the tongue):
– Massive lesions that exceed the border of
the hemilingual area of origin inltrating
the ipsilateral base of the tongue and the
contralateral genioglossus muscle
• Type V glossectomy (total glossectomy)—
The specimen includes all of the mobile
tongue and the base of the tongue transected at
the level of the vallecula; it includes intrinsic
and extrinsic muscles, both lingual arteries,
hypoglossal, lingual nerves and the oor of
the mouth:
– Massive inltrating lesions, for instance,
those of the anterior ventral surface of the
tongue, dorsum of the tongue or the tongue
base, which bilaterally involve the extrinsic
genioglossus, hyoglossus and styloglossus
with impairment of the mobility of the
tongue.
2.2 Indications forPeroral
Approach
• Good mouth opening.
• All of the tumour margins are visible.
• Anteriorly placed tumours.
• Able to perform satisfactory reconstruction.
2.3 Indications forLower Cheek
Flap Approach
• Trismus.
• Deep inltrative tumours.
• Posteriorly placed tumours.
• Tumours reaching the base of the tongue.
• Need for composite resection.
2.4 Indications forVisor Approach
• Trismus.
• Posteriorly placed tumours.
• Total or near-total glossectomy.
Follow-up photographs of surgical excision of
tongue malignancy are depicted in Figs. 9, 10,
11, 12, 13 and 14.
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Fig. 9 Wedge primary closure following tongue-wide
local excision
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Fig. 11 Tongue defect left to heal by secondary
intention
Fig. 10 Longitudinal closure helps in maintaining the tip
and tongue length
2.5 Reconstruction Options
forTongue Defects
• Partial glossectomy defects:
– Primary closure:
Wedge closure.
Longitudinal.
– Healing by secondary intention.
– Pedicled aps:
Facial artery myomucosal aps.
Nasolabial aps.
Fig. 12 Follow-up after 6months
Submental aps.
Infrahyoid ap.
Supraclavicular ap.
Pectoralis major myofascial ap
(PMMF).
– Free Flap.
Radial free forearm ap.
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Fig. 13 One-year follow-up after wedge closure
N. M. Nagarkar et al.
• Hemiglossectomy defects.
– Pedicled aps.
Facial artery myomucosal aps.
Nasolabial aps.
Submental aps.
Infrahyoid ap.
Supraclavicular ap.
Pectoralis major myofascial ap
(PMMF).
– Free Flap.
Radial free forearm ap.
Anterolateral thigh ap.
Free bula osseocutaneous ap
(FFOCF) for composite defects.
• Total or near-total glossectomy.
– Pedicled aps:
Pectoralis major myocutaneous ap.
– Free aps:
Free radial forearm ap.
Free anterolateral thigh ap.
The specimen of tongue composite lingual
plate marginal mandibulectomy is shown in
Fig.15.
Surgical steps for islanded nasolabial ap for
reconstruction following tongue-wide local excision are depicted in Figs.16, 17, 18, 19, 20 and
21.
Patient underwent tongue-wide local excision
with free radial forearm ap reconstruction that
is shown in Figs.22 and 23.
Follow-up photos are depicted in Figs.24, 25,
26, 27, 28, 29 and 30.
Fig. 14 One-month follow-up following Trotter’s procedure for the base of tongue tumour excision
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Fig. 15 Specimen of tongue composite lingual plate marginal mandibulectomy
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Fig. 16 Marking for islanded nasolabial ap reconstruction for tongue defects
Fig. 17 Islanded nasolabial ap with its intact vessels
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N. M. Nagarkar et al.
Fig. 20 Intraoral photo showing the nasolabial ap tting into the defect like a jigsaw
Fig. 18 Islanded nasolabial ap with its intact blood
vessels
Fig. 19 Following islanded nasolabial ap inset
Fig. 21 Hair growth on the ap indicates good ap vas-
cularity. Depilation may be required if hair growth is
troublesome
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Fig. 22 McGregor incision and cheek ap approach for
the tongue composite resection
Fig. 23 Postoperative picture showing the free radial
artery forearm ap reconstruction following hemiglossectomy composite segmental mandibulectomy
Fig. 24 Excellent scar following nasolabial ap
reconstruction
Fig. 25 Well-healed scar following tongue composite
resection
Fig. 26 En face view shows negligible scar following
reconstruction
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Fig. 27 One-year follow-up showing good graft uptake
in the left radial forearm
N. M. Nagarkar et al.
Fig. 28 Excellent mucosalisation of the islanded nasolabial ap, fourth month of follow-up
Fig. 29 (a, b) One-year follow-up after hemiglossectomy with free radial forearm ap
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Fig. 30 Total glossectomy with free radial forearm
reconstruction
3 Principles ofManagement
ofBuccoalveolar Cancers
Carcinoma of the buccal mucosa represents
5–10% of all oral cavity malignancies and has a
4: 1 male predominance; the typical patient is in
the sixth decade of life. An association between
smokeless tobacco use and buccal carcinomas
has been noted, and an increased incidence of
these tumours is seen in the western population.
In India, betel nut use is associated with a high
incidence of buccal carcinoma.
The site of the buccal mucosa where squamous carcinoma is most frequently noted is adjacent to the third mandibular molar. Patients with
advanced-stage disease may present with trismus
as a result of direct invasion of the tumour into
the muscles of mastication, and parotid duct
involvement may produce obstructive sialadenitis. Anterior lesions metastasise regionally to
submandibular nodes, whereas posterior buccal
lesions metastasise to upper jugulodigastric
lymph nodes:
• Small lesions can be excised transorally.
• Intermediate-stage primary tumours may be
resected transorally or through a lip-splitting
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incision. With the exception of supercial
lesions, the buccinator muscle should be
resected in continuity to provide adequate
margin depth.
• Adequate subcutaneous fat must be left behind
to ensure viability of the skin, whenever oncologically safe. Palpation must be done at every
step to ensure the button hole of the buccal
skin is not created.
• Local intraoral spread may necessitate resection of the alveolar ridge of the mandible or
maxilla. Deep invasion into the cheek may
require through-and-through resection.
• Peroral: Small anterior lesions are accessible
without an external incision. However a peroral approach should be avoided in posterior
lesions even if they are small. It is pertinent to
resect an adequate base with wide margins as
the base is the commonest site of compromised margins with peroral excision.
Occasionally an anterior lesion requiring marginal mandibulectomy can be approached
perorally.
• Cheek ap: Most lesions of the buccal mucosa
(with above exceptions) are approached via a
cheek ap with straight lip split, angle split or
McGregor incision.
• Midline lip split: When a lesion is located
away from the oral commissure, the lip is split
in the midline. This incision maintains better
oral competence. The incision is continued
over the mentum, curving towards the hyoid
up to the mastoid process along a suitable skin
crease at least two nger breadths below the
mandible. The midline lip split incision can be
modied for better cosmesis.
The wide variation in the presentation of the
lesion over the buccal mucosa is depicted in
Figs.31, 32, 33, 34, 35 and 36.
3.1 Management oftheMandible
• Periosteum is a robust barrier to bone invasion. The mandible is generally invaded via its
occlusal surface in alveolar lesions with intact
dentition. In the retromolar trigone or in eden-
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N. M. Nagarkar et al.
Fig. 31 Growth in the left buccal mucosa
Fig. 32 Hypertrophic leukoplakic patch in the right buc-
cal mucosa
tulous mandibles, the occlusal surface corresponds to the junction of the attached and
reected mucosa (point of abutment).
• In irradiated mandibles and in large tumours,
the mandible can be invaded at multiple points
due to multiple breaks in the periosteum.
• With cancers of the oor of the mouth, the
mandible is inltrated at the point of abutment. Hence a horizontal marginal mandibulectomy can be attempted in early
gingivobuccal complex cancer lesions to
include invasion at the occlusal surface; the
oor of mouth cancer requires vertical or
oblique marginal mandibulectomy to
Fig. 33 Verrucous growth in the left buccal mucosa
Fig. 34 Ulceroproliferative growth in the left buccal
mucosa
completely excise the lingual plate due to
invasion occurring directly at the point of
abutment.
• Marginal mandibulectomy—Marginal mandibulectomy is indicated when tumour abuts
the mandible without gross invasion or when
there is only supercial bony invasion
(Figs.37, 38, 39, 40, 41 and 42):
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