HEMIGLOSECTOMY&

RECONSTRUCTIONDr. Erami M.D.ENT Resident

Department Of ENTShahid Sadoghi Hospital

Yazd Iran

• oral cavity malignancies:• early-stage • can be associated with excellent oncologic control

•Advanced-stage • require combined modality therapy • surgical resection + adjuvant radiation +/- chemotherapy

• Treatment Options:

• T1N0, T2N0 Surgery ± RT

RT -External Beam-Brachytherapy

• T3N0, T4N0 Surgery and Post op RTN+ ± Chemotherapy

• T4b, N3, M+ PALLIATION- Primarily RT ± Chemo

CURATIVE

•primary importance in preoperative treatment planning:• Extension to the lingual aspect of the mandible

(Anterior or lateral extension)

• Imaging studies of the mandible:• CT•MRI• Panorex

are useful in conjunction with• careful clinical evaluation:• bimanual palpation (adherence to the mandible)

• The surgical approach is dictated by the:• size of the tumor• location of the tumor• the anatomic region

• Invasion into muscles:• can lead to tongue hypomobility and dysarthria• genioglossus, mylohyoid, and hyoglossus muscles

• Fixation :• tumors of the anterior floor of the mouth may extendposteriorly into the ventral aspect or “root” of the tongue

Floor of the Mouth

• The treatment of choice:

• For early-stage lesions (T1 and small T2s) without mandibular involvement:• Trans oral resection

• For more extensive anterior and lateral floor-of-mouth cancers without mandibular involvement:• a pull-through technique

(can obviate the need to perform a mandibulotomy)

• For some posterior floor-of-mouth tumors without mandibular involvement:• Paramedian or lateral mandibulotomy

• For lesions that involve the lingual periosteum without evidence of bony invasion:• A coronal partial mandibulectomy may be required

• For massive lesions with mandibular destruction:• composite resection with segmental mandibulectomy

• For lesions that radiographically detected bony erosion fails to extend below the level of the mandibular canal

(in the setting of alveolar ridge carcinoma)•Marginal resection (some authors has been advocated )

• Lesions in the anterior floor of the mouth may directly invade:

• the sublingual salivary gland• submandibular duct

• require in-continuity resection with the primary lesion

• visor or degloving approach:• Advanced-stage tumors without mandibular involvement• the anterior oral tongue and floor of the mouth (in particular involve the genioglossus and mylohyoid)

•mandibulotomy:• provide adequate access for the resection of the posterior

margin• allow for reconstruction•will require postoperative radiation (most patients with advanced

tumors)• Irradiation to the mandibulotomy site may predispose the

patient:• radiation necrosis• Nonunion

Indications for Surgical Treatment of the Mandible

sagittal-lingual marginal mandibulectomy

marginal versus segmentalmandibulectomy

composite resection with segmental mandibulectomy

•Mandible-sparing procedures:• vertical marginal mandibulectomy• lingual-sagittal marginal mandibulectomy• Floor-of-mouth tumor

• Horizontal marginal mandibulectomy• coronal “rim” marginal mandibulectomy• Floor-of-mouth–alveolar ridge tumor

• pull-through techniques• offer the advantage of avoiding a lip-splitting incision• allow adequate exposure for free tissue reconstruction

• Contraindicated:• gross mandibular destruction(but may be performed in continuity with resection of the lingual plate of the mandible)

pull-through approachlingual-sagittal marginal mandibulectomy

coronal “rim” marginal mandibulectomy

Anterior floor-of-mouth treated: marginal mandibulectomy

(Teeth are extracted at the sitesof the osteotomy cuts)

A, Anterior view of marginal mandibulectomyapproach with wide local excision for floor-of-mouth carcinoma

B, Sagittal view demonstrates bone and soft tissue cuts superficial to the geniohyoidand mylohyoid muscles.

• SURGICAL TREATMENT OF THE NECK:• As a rule:• If the primary tumor is treated with surgerythe neck is generally managed surgically• If the primary tumor is treated with radiationthe neck is treated similarly

• Cervical metastases:• are noted in approximately 50% of patients with floor-of-mouth

carcinoma• The submandibular lymph nodes (level Ib) are most frequently involved• Bilateral metastases are common with lesions of the anterior floor of the

mouth

• Primary tumors within the oral cavity and lip typically metastasize• nodes in levels I, II, and III

• oral cavity malignancy with clinically and radiographically N0, with a risk of occult metastases that exceeds 20% :• elective treatment to the regional lymphatics

• limited N1 disease• Some authors advocate SND

• For the clinically node-positive neck, the surgical treatment of choice:•MRND or RND

• for selecting patients for END and association with the likelihood for occult spread of tongue cancer• tumor thickness• Perineural invasion• level of differentiation• T staging• invasion margin

•Midline lesions :• bilateral neck dissection

• The most common SND:• supraomohyoid neck dissection (SOHND)

Includes levels I, II, and III

• standard of care for an SOHND:(in the setting of an oral cancer) • submandibular gland dissection with level Ib

• some authors disagree that:• Inclusion of level IIb is necessary in the setting of elective neck

dissection (END)

oral cavity tumors: (Neck Dissection)• levels I to III• Also called supraomohyoid neck dissection

•Oral tongue: • level I-IV

• Contralateral ND: primary lesions that involve the• floor of the mouth• the ventral surface of the tongue•midline involvement of the tongue

•postoperative adjuvant radiation therapy: • adjuvant radiation therapy for High-risk pathologic features: • extranodal tumor spread• involved surgical margins• T3/T4 tumors• Perineural invasion• lymphovascular space invasion• low-neck adenopathy (level IV)• multiple tumor-involved cervical lymph nodes (N2b/N2c)

• “closed margin” for oral cavity carcinoma:• a margin of 4 mm or less

• Aggressive dental care in these patients by a dentist skilled in managing patients who require radiation therapy is essential.

Brachytherapy:• Brachytherapy catheter placement for localized radiation boost has a limited role

in the treatment of oral malignancies• Brachytherapy as a primary treatment:• has not been advocated because of :• the creation of post treatment fibrosis (limits monitoring for recurrence)

CHEMOTHERAPY:• standard chemoradiotherapy platform for head and neck cancer treatment:• Postoperative radiotherapy concurrent with cisplatin at 100 mg/m2 every 21

days

•RECONSTRUCTION:• important principles:•maximizing mobility of the remaining tongue• reconstructing adequate bulk• obtaining adequate access to inset tissue for reconstruction• performing a watertight closure• reconstructing the appropriate sulci

(such that prosthetic rehabilitation is not hindered)

• The goals of reconstruction :• a watertight closure (to avoid salivary fistula)

• preserve tongue mobility

• resection of small lesions, options include :• primary closure• split-thickness skin or dermal grafting• heal by secondary intention

• various advancement and rotation flaps:• Use of buccal fat• Use of temporoparietal fascia• Use of pectoralis major

•Reconstructive Options:• For extensive mucosal and soft tissue deficits:• the best reconstructive option:• The radial forearm free flap

• For small lateral defects:• Nasolabial flap• Platysmal flap

• for larger soft tissue defects:(preferably when the posterolateral mandible is resected)• Pectoralis major myocutaneous flap

•Mandibular difects:

• Segmental resections of the anterior mandible :(including the symphyseal and parasymphyseal regions)

• Reconstruction with vascularized bone and soft tissue

• Posterior segmental mandibular defects:particular in :edentulous patientsindividuals with comorbidities that limit the possibility for free tissue bony reconstruction

• Repaired with soft tissue reconstruction only

• INDICATIONS FOR FREE FLAP :

• The pectoralis major flap:• For full-thickness buccal defects and extensive glossectomy defects

• can be partially deepithelialized or rotated back on itself:• to provide resurfacing of the oral cavity components and the external

lower one third of the face

• However, the optimal treatment for many of these complex defects often requires microvascular free tissue reconstruction

• The radial forearm free flap:• allows for a reconstruction tailored in shape to the oral defect

without the burden of excessive bulk• offers the option for neural anastomosis, thus providing sensate

reconstruction• and is associated with limited donor-site morbidity

• When additional soft tissue is required:• the anterolateral thigh• The rectus• The parascapular-scapular flaps• may be harvested with larger skin paddles and associated muscle

for additional bulk.• scapular composite flap:• offers the advantage of multiple skin paddles with bone

• Indications for a fibula osteocutaneous free flap reconstruction:• total-subtotal mandibular reconstruction• reconstruction of “bone-only” defects (ORN)• Reconstruction of the atrophic mandible• pediatric mandibular reconstruction• secondary reconstruction of the subcondylar-condylar complex

Fibular free flap reconstruction of the segmental mandibulardefect and of the soft tissue defect of the floor of the mouth andthe tongue. Vessel anastomosis is noted in the neck

• Submental island flap:

• Thin, supple skin• Submental branch of facial artery• Primary closure of donor site• Poor reliability if:

• Facial artery sacrificed• Irradiated necks

• the incisions of the submental island flap were designed and marked Based on :• The result of pinch test• The lesion of the primary tumor

• Design of the submental island flap• Submental vein (blue) accompanying the submental artery.

Preoperaive view

Preoperativeflap design

Operative incision of the submental island flap

Defect after the excision of the lesion

The flapbeing harvested to the defect

The flapbeing harvested to the defect

The flapbeing harvested to the defect

Floor of Mouth Platysma Flap Reconstruction

Floor of Mouth Platysma Flap Reconstruction

Floor of Mouth Platysma Flap Reconstruction

Floor of Mouth Platysma Flap Reconstruction

Floor of Mouth Platysma Flap Reconstruction

Thanks for your

attention