Anda di halaman 1dari 10

2004 WebMD, Inc. All rights reserved.

ACS Surgery: Principles and Practice

2 HEAD AND NECK

4 ORAL CAVITY PROCEDURES 1

ORAL CAVITY PROCEDURES

Carol R. Bradford, M.D., F.A.C.S., and Mark E. Prince, M.D., F.R.C.S.(C)

Preoperative Evaluation

Oral cavity procedures are commonly performed to treat malignancies. Tumors should be assessed preoperatively to allow accurate staging of the disease and to facilitate planning of definitive
treatment. In most cases, an examination under anesthesia with
endoscopy and biopsy is required to stage the primary tumor and
to look for synchronous second primary tumors. Except in the
case of very superficial lesions, computed tomography plays an
important role in preoperative planning. In selected cases, plain
radiographs (e.g., Panorex views) may be useful in evaluating the
mandible.When the lesion is located in the tongue, magnetic resonance imaging may provide additional information about the
extent of the primary tumor.
Wide surgical margins are necessary for adequate treatment of
primary squamous cell carcinoma of the head and neck. A margin of 1 to 2 cm should be achieved whenever possible, ideally
with frozen-section control. Current evidence clearly indicates
that overall patient outcome improves when clear margins are
obtained.
Nodal metastases are common with oral cavity tumors. Accordingly, patients should be assessed for cervical adenopathy both
clinically and radiographically. A chest x-ray should be obtained in
all cases. CT or MRI can provide valuable information regarding
the nodal status of the neck. In patients with advanced disease, a
more extensive search for distant metastases should be conducted,
including a CT scan of the chest. In some circumstances, combining CT with positron emission tomography (PET) may be
useful.
Operative Planning

Surgical management of the neck is an evolving field. In general, if the risk of occult metastasis is greater than 20% to 25%, a
selective neck dissection [see 2:6 Neck Dissection] is recommended, particularly if postoperative radiation therapy is not planned.
Whenever there is clinical evidence of nodal disease, treatment of
the neck must be included in operative planning.
The oral cavity is a major component of a number of important functions, including speech and swallowing. Reconstruction
of the anticipated surgical defect must be carefully planned to
achieve the best results. Several basic considerations must be kept
in mind. Tongue mobility and sensation must be maintained to
the extent possible. Maintenance of mandibular continuity (especially in the anterior segment of the mandible) is vital for ensuring postoperative oral competence. Separation of the nasal cavity
from the oral cavity is critical for the oral phase of swallowing and
speech. Maintenance of the gingivobuccal and gingivolabial sulcus is important for oral function and the fitting of dentures.
As a rule, oral cavity defects should be closed primarily whenever possible. Primary closure has the advantage of using sensate
tissue similar in form to the tissue that was excised. With experience and careful judgment, the surgeon can usually determine
when a defect is too large for primary closure or when primary
closure is likely to cause distortion and tethering of adjacent tis-

sues and result in a significant functional disturbance. In such


cases, a flap reconstruction must be considered. In select cases,
pedicled flaps may be appropriate. Often, particularly with larger
or more complicated defects, free flaps provide the best reconstructive result. Free tissue reconstruction has the advantage of
allowing the surgeon to reconstruct the defect with the exact tissue components that were excised, including bone and skin. In
addition, free flaps can be reinnervated to achieve a sensate
reconstruction.
If the planned surgical procedure involves resection of part of
the maxilla or the mandible, appropriate dental consultation
should be obtained. If a postoperative splint, obturator, or dental
prosthesis is to be placed, it is critical that dental impressions be
obtained before operation. Thyroid function should be tested in
all patients who have a history of radiation therapy to the neck to
confirm that they are euthyroid.
In cooperative patients, small primary lesions of the oral cavity can sometimes be excised with local anesthesia; however, general anesthesia with adequate relaxation is required in the majority of cases.The route of intubation must be carefully considered
for each patient. When the planned resection is extensive and
when significant postoperative edema is anticipated, a tracheostomy should be performed. Patients with bulky lesions should
undergo tracheostomy under local anesthesia before general
anesthesia is induced.When a tracheostomy is not planned, nasotracheal intubation is often desirable.
When the excision is limited to the oral cavity, perioperative
antibiotics are generally unnecessary. When a graft, a flap, or
packing is employed, however, perioperative I.V. administration
of antibiotics is advisable. In all cases in which the neck is
entered, perioperative antibiotics are recommended. The oral
cavity can be prepared preoperatively with chlorhexidine and a
toothbrush.
A nasogastric feeding tube should be inserted whenever it is
believed that the patient may have a problem maintaining oral
nutrition postoperatively. Patients who undergo primary closure
or split-thickness skin grafting or whose surgical wound is allowed to heal by secondary intention may be allowed clear liquids
in 24 to 48 hours and a pureed diet by postoperative day 3;
they can often tolerate a soft diet within 1 week. Patients who
undergo flap reconstruction will have to be fed via a nasogastric
tube until they have healed to the point where they can resume
oral intake.
Patients should be advised to maintain oral hygiene postoperatively by means of frequent irrigation and rinses with either normal saline or half-strength hydrogen peroxide.Teeth may be gently cleaned with a soft toothbrush until healing has occurred.
Anterior Glossectomy
OPERATIVE PLANNING

Either orotracheal or nasotracheal intubation may be appropriate, depending on the surgical approach and the extent of the

2004 WebMD, Inc. All rights reserved.


2 HEAD AND NECK

ACS Surgery: Principles and Practice


4 ORAL CAVITY PROCEDURES 2

planned resection. A tracheostomy should be performed whenever significant postoperative swelling or airway compromise is
anticipated.
The depth of the excision and the size of the anticipated defect
determine the optimal reconstructive approach. Defects that
connect to the neck, unless they are small and can easily be
closed primarily, usually necessitate creation of a flap for optimal
reconstruction. When the excision extends down to the underlying musculature but there is no connection to the neck, a skin
graft may be used. If a postoperative dental splint is planned to
hold a skin graft in place, a dental consultation must be obtained
before operation.
The patient should be supine in a 20 reverse Trendelenburg
position. Turning the table 180 may facilitate access and positioning for the surgeon.
OPERATIVE TECHNIQUE

Step 1: Surgical Approach


Small anterior lesions up to 2 cm in diameter may be
approached transorally, as may certain carefully selected larger
lesions. Exposure of the tongue is usually achieved with the help
of an appropriately sized bite block; alternatively, a specialized
retractor (e.g., a Molt retractor) may be used. Retraction of the
tongue is facilitated by the use of a piercing towel clip or a heavy
silk suture placed through the tip of the tongue.
Access to posterior lesions and most larger lesions is obtained by
performing a mandibulotomy through a lip-splitting incision [see
Figure 1]. A stair-step incision is made in the lip and extended
downward straight through the mentum, and a Z-plasty is done at
the mental crease. Alternatively, the incision may be carried around
the mental subunit.
The mandibular periosteum is elevated and a plate contoured to
the mandible before the mandible is divided; this measure ensures
exact realignment of the cut ends of the mandible.When possible,
the mandibulotomy should be made anterior to the mental foramen to preserve sensation throughout the distribution of the mental nerve. Repair of the mandibulotomy is greatly facilitated by
making a stair-step or chevron-type mandibulotomy [see Figure 2].
A paralingual mucosal incision is made to allow retraction of the
mandible and exposure of the posterior oral cavity.
As an alternative, a visor flap may be created [see Figure 3]. Such
a flap allows the surgeon to avoid making a lip-splitting incision and
provides adequate exposure of small lesions of the anterior oral cavity; however, it is inadequate for exposure of lesions posterior to the
middle third of the tongue or in the area of the retromolar trigone.
Furthermore, creation of a visor flap results in anesthesia of the
lower lip because of the necessity of dividing both mental nerves.
To create a visor flap, an incision is made from mastoid to
mastoid along a skin crease in the neck, with care taken to remain
below the marginal mandibular nerves. The skin flap is elevated
in the subplatysmal plane to the level of the mandible. The marginal mandibular nerves are preserved. The flap is elevated from
the lateral surface of the mandible, and the two mental nerves are
divided. An incision is made in the oral cavity mucosa along the
gingivolabial sulcus and continued so that it connects to the skin
incision. The flap is then retracted superiorly to expose the anterior mandible and the oral cavity.
Step 2: Resection
The excision should include a generous mucosal margin
around the visible lesion. A significant amount of the tongue
musculature surrounding the lesion should be resected as well.

Figure 1 Anterior glossectomy. A lip-splitting incision is


made that extends downward straight through the mentum.

Palpation of the lesion is critical for obtaining adequate deep surgical margins.
Resection may be performed with a monopolar electrocautery,
with the cutting current used to incise the mucosa and the coagulation current used to cut the muscle. Alternatively, resection
may be performed with a scalpel and a scissors. Hemostasis is
achieved with a monopolar or bipolar electrocautery. Larger vessels are ligated with chromic catgut or Vicryl ties.
Lesions of the lateral tongue should be wedge-excised in a
transverse (rather than horizontal) fashion to facilitate closure
and enhance postoperative function. With larger lesions, for
which either flap reconstruction or healing by secondary intention is typically indicated, the shape of the defect is contoured so
as to obtain wide margins around the lesion, and the flap is
designed to fill the contoured defect.
Step 3: Reconstruction
After negative margins are confirmed by frozen section examination, repair of the surgical defect is initiated. Careful preoperative
assessment of the anticipated defect lays the groundwork for optimal reconstruction. Many defects can be either repaired primarily
or allowed to heal by secondary intention. Free tissue transfer is an
excellent reconstructive option in many cases, allowing the maintenance of tongue mobility and the separation of the tongue from the
mandible and making sensate reconstruction possible.
In many patients with wedge-excised lateral tongue lesions, primary closure of the defect yields good results.The deep muscle is
carefully reapproximated with long-lasting absorbable sutures.The
mucosa is also closed with absorbable sutures. Care should be taken not to strangulate tissues by making the sutures too tight.When
complete primary closure is not possible or desirable, the tongue
may be allowed to granulate and heal by secondary intention. Splitthickness skin grafts, though useful for relining the floor of the
mouth, generally do not take well on the tongue.
For large defects of the tongue and those involving the floor of
the mouth, flap reconstruction is appropriate. Defects that connect to the neck, unless they are small and can be closed primarily, should also be closed with a flap. Free tissue transfer is frequently the optimal reconstructive approach. Free fasciocuta-

2004 WebMD, Inc. All rights reserved.

ACS Surgery: Principles and Practice

2 HEAD AND NECK

4 ORAL CAVITY PROCEDURES 3


after 7 to 10 days. Patients with skin grafts should stay on a soft
diet for 2 weeks. If a tracheotomy was performed, the patient may
be decannulated when postoperative edema has settled.
Meticulous and frequent oral hygiene is essential. Mouth rinses and irrigation with normal saline or half-strength hydrogen
peroxide should be done at least four times a day and after every
meal. Teeth may be gently cleaned with a soft toothbrush.
COMPLICATIONS

The main complications of anterior glossectomy are as follows:


1. Injury to the lingual nerve, which causes numbness and loss
of the sense of taste in the ipsilateral tongue.
2. Injury to the submandibular and sublingual gland ducts, which
causes obstruction of the glands, pain and swelling, and possibly ranula formation.
3. Injury to the hypoglossal nerve, portions of which are resected with the lesion. Injury to the main trunk of this nerve leads
to paralysis and atrophy of the remaining ipsilateral tongue.
4. Tethering and scarring of the tongue, which can lead to difficulties with speech and swallowing.This problem can usually be
avoided by careful preoperative planning of reconstruction.

Figure 2 Anterior glossectomy. A stair-step mandibulotomy


is made.

neous flaps from the radial forearm, the anterior lateral thigh, or
the lateral arm are well suited to reconstruction in this area.
Pedicled flaps (e.g., myocutaneous flaps from the pectoral muscle) are also used in this setting, but they are bulkier and harder
to contour to the defects.
If a mandibulotomy was made, it is repaired with the previously contoured plate. The lip-splitting incision is closed in three
layers (mucosa, muscle, and skin). Great care must be taken to
ensure accurate realignment of the vermilion border and the
orbicularis oris muscle.
Alternative Procedure: Laser Vaporization
Very superficial and premalignant lesions of the tongue may be
vaporized by using a CO2 laser. The desired depth of tissue
destruction for leukoplakia is approximately 1 to 2 mm.
TROUBLESHOOTING

Larger excisions may lead to airway edema.Whenever this possibility is a concern, a tracheostomy should be performed. A single intraoperative dose of steroids may reduce postoperative
tongue edema without adversely affecting wound healing. Using
a stair-step incision for the lip-splitting incision facilitates accurate reapproximation of the vermilion border. Excessive tongue
movement may result in dehiscence of the closure. Voice rest for
3 to 5 days after operation may be beneficial.
POSTOPERATIVE CARE

Patients who undergo primary closure of the tongue may begin a


fluid diet on the day after operation; they should remain on a liquid
diet for 7 to 10 days. Patients who undergo skin grafting may also
begin a liquid diet on postoperative day 1. If a flap was used to close
the defect or if there is some question whether the patient will be capable of adequate oral intake, a nasogastric feeding tube should be
inserted and maintained until the suture lines heal.
Bolster dressings may be removed and skin grafts inspected

Figure 3 Anterior glossectomy. As an alternative to a lip-splitting incision with mandibulotomy, a visor flap may be employed
for exposure.

2004 WebMD, Inc. All rights reserved.

ACS Surgery: Principles and Practice

2 HEAD AND NECK


Excision of Floor-of-Mouth Lesions
OPERATIVE PLANNING

Planning for excision of a lesion from the floor of the mouth is


essentially the same as that for anterior glossectomy [see Anterior
Glossectomy, Operative Planning, above]. If either or both of
Whartons ducts are to be transected without excision of the submandibular glands, consideration must be given to the management of these glands.
OPERATIVE TECHNIQUE

Step 1: Surgical Approach


The surgical approach is the same as that described for glossectomy [see Anterior Glossectomy, Operative Technique, Step 1, above].
Step 2: Resection
The area to be excised, including adequate margins, is marked.
The lesion is then excised with a monopolar electrocautery; as in
a glossectomy, the cutting current is used to cut the mucosa, the
coagulation current to cut the deeper tissues. Palpation is important for obtaining adequate deep surgical margins.
If the excision cuts across Whartons duct, the duct should be
identified and transected obliquely so as to create a wider opening. The transected stump is held with a 4-0 chromic catgut
suture. Once the resection is complete, the duct is transposed
posteriorly to the cut edge of the mucosa of the floor of the mouth
and sutured in place with two or three 4-0 chromic sutures.
During subsequent reconstruction, care should be taken not to
obstruct the orifice of the duct.
Step 3: Reconstruction
After clean surgical margins have been verified by frozen section examination, repair of the surgical defect is initiated. Small
superficial defects of the floor of the mouth may be allowed to
heal by secondary intention.
For small defects that do not connect to the neck, reconstruction with a 0.014 to 0.016 in.thick split-thickness skin graft is
appropriate.The graft is cut to size and sutured in place with 4-0
chromic sutures. Several perforations should be made in the graft
to allow the egress of blood and serum. A Xeroform gauze bolster is fashioned to fit over the skin graft and sutured in place with
2-0 silk tie-over bolster stitches; alternatively, it may be held in
place by a prefabricated dental prosthesis.
For larger defects, particularly those involving the tongue, a flap
reconstruction typically yields the best functional results. In select
cases, a platysma flap may be used for reconstruction of defects in
the floor of the mouth. Other regional flaps tend to be bulky and
difficult to shape to the contours of the defect. Free tissue transfer
frequently provides the most suitable reconstructive tissue characteristics and the most favorable postoperative results. A free fasciocutaneous radial forearm flap is usually the optimal choice for reconstruction of floor-of-mouth defects when a flap is required.
TROUBLESHOOTING

Special care should be taken to identify the lingual nerve and


artery so that these structures are not inadvertently divided.
Meticulous hemostasis should be obtained in all cases. Any skin
grafts used should be adequately sized and should not tent up.
Generally, skin grafting and bolsters do not work well on mobile
structures. Quilting grafts to the underlying tissues with multiple
absorbable sutures can eliminate the need for a bolster and result
in acceptable graft take.

4 ORAL CAVITY PROCEDURES 4


POSTOPERATIVE CARE

Postoperative care of patients undergoing excision of floor-ofmouth lesions is virtually identical to that of patients undergoing
anterior glossectomy [see Anterior Glossectomy, Postoperative
Care, above].
COMPLICATIONS

Excision of floor-of-mouth lesions is associated with the same


complications as anterior glossectomy [see Anterior Glossectomy,
Complications, above].
Excision of Superficial or Plunging Ranulas
OPERATIVE PLANNING

Planning for excision of a superficial or plunging ranula resembles that for glossectomy. A Ring-Adair-Elwyn (RAE) tube is inserted orally and taped to the contralateral cheek. Cervical exploration is usually unnecessary, because the cervical component of
the ranula resolves after removal of the ipsilateral sublingual gland.
In select cases, especially those involving disease recurrence after a
previous attempt at excision, a transcervical approach should be
considered.
OPERATIVE TECHNIQUE

Step 1: Surgical Approach


Ranulas are resected via the transoral approach. A bite block or
a Molt retractor is used to gain exposure.
Step 2: Resection
A local anesthetic preparation with epinephrine is infiltrated
into the area of the mucosal incisions. A small superficial ranula
may be marsupialized and packed with gauze.The ranula is widely unroofed and the contents removed with suction.The margins
of the cyst are sutured to the mucosa with 4-0 chromic sutures,
and the cavity is packed with iodoform strip gauze. The gauze
may be removed in 5 to 7 days.
A plunging ranula is treated with complete surgical excision of
the cyst and the sublingual gland [see Figure 4]. A mucosal incision is made directly over the cyst. Careful dissection is carried
out around the cyst and the associated gland. Hemostasis is
achieved with a bipolar electrocautery, with care taken not to
injure the adjacent lingual nerve. The submandibular gland duct
is cannulated with a lacrimal probe to help guard against inadvertent injury to this structure. The incision is closed with 4-0
chromic suture.
TROUBLESHOOTING

Efforts should be made to identify the lingual nerve and artery


so as to prevent inadvertent division of these structures. Meticulous hemostasis should be obtained in all cases. If the submandibular gland duct is injured, it should be transected and the
cut end sutured to the adjacent floor-of-mouth mucosa
(sialodochoplasty).
COMPLICATIONS

The three main complications of the procedure for excising a


ranula are among those that are also associated with anterior glossectomy and excision of floor-of-mouth lesions: injury to the lingual nerve, injury to the submandibular gland duct, and injury
to the hypoglossal nerve [see Anterior Glossectomy, Complications, above].

2004 WebMD, Inc. All rights reserved.

ACS Surgery: Principles and Practice

2 HEAD AND NECK

4 ORAL CAVITY PROCEDURES 5


TROUBLESHOOTING

Careful dissection directly onto the duct and stone usually


serves to prevent inadvertent injury to the lingual nerve.
COMPLICATIONS

The main complications of the procedure are as follows:


1. Injury to the lingual nerve, resulting in numbness and loss
of the sense of taste to the ipsilateral tongue.
2. Stricture of the submandibular gland duct.This is an unusual complication that can be corrected by transecting the duct
posterior to the stricture and suturing it to the mucosa of the
floor of the mouth.
Resection of Hard Palate
OPERATIVE PLANNING

Cyst
Gland

Careful evaluation is required to determine whether resection


of part of the hard palate will suffice or whether a more extensive
dissection (e.g., maxillectomy) will be required. If it is anticipated that a dental prosthesis will be required, a dental consultation
should be obtained before operation. When the lesion to be
resected is superficial or only a limited amount of the bony hard
palate must be resected, the procedure may be performed via the
transoral approach.
OPERATIVE TECHNIQUE

Figure 4 Excision of plunging ranula. A mucosal incision is


made over the cyst, dissection is done around the cyst and the
associated sublingual gland, and cyst and gland are completely
excised.

Removal of Submandibular Gland Duct Stones


OPERATIVE PLANNING

When a submandibular gland duct stone is readily palpable in


the floor of the mouth, a transoral approach is appropriate.When
the stone is within the hilum of the gland, however, it generally
cannot be removed transorally and often must be treated by
excising the submandibular gland.
OPERATIVE TECHNIQUE

Step 1: Surgical Approach


The procedure is easily accomplished with local anesthesia
in a cooperative patient. The patient is seated upright in the
examining chair, and a topical anesthetic is applied to the oral
cavity.
Step 2: Resection
A local anesthetic preparation with epinephrine is infiltrated
into the floor of the mouth and around the duct in which the
stone is palpated. A 2-0 silk suture may be placed around the duct
behind the stone to prevent it from migrating back into the hilum
of the gland.
A lacrimal probe is inserted into the duct and advanced to the
stone in a retrograde manner. A mucosal incision is then made
directly over the stone and extended downward to the duct, with
the stone and the lacrimal probe serving as guides. The duct is
incised and the stone delivered. As a rule, repair of the duct is not
required.

Step 1: Surgical Approach


The patient is supine, with the bed turned 180 to facilitate the
surgeons access to the operative site. An oral RAE tube is inserted and taped in the midline. The lesion is approached transorally, and a Dingman or Crowe-Davis retractor is used to obtain
exposure.
Step 2: Resection
An incision is made around the periphery of the lesion in such
a way as to maintain adequate margins; a monopolar electrocautery with a needle tip is ideal for this purpose.The periosteum
is elevated away from the underlying bone, and the lesion is
removed [see Figure 5].
When bone must be resected, the periosteum is elevated away
from the incision site. A high-speed oscillating saw or an osteotome is used to make the cuts in the bone, after which the specimen is rocked free and removed.
Step 3: Reconstruction
After surgical margins have been verified by frozen-section
review, repair of the surgical defect is initiated. Small mucosal
defects may be allowed to heal by secondary intention. Small
through-and-through resections may be closed by placing relaxing incisions laterally and advancing the mucosa to permit primary closure. Larger defects may be closed with palatal mucosal
flaps. Many through-and-through defects can be closed quite satisfactorily with a dental obturator.
POSTOPERATIVE CARE

The patient should be maintained on a soft diet postoperatively. Meticulous oral hygiene is important. Oral rinses and flushes
with normal saline or half-strength hydrogen peroxide should be
performed at least four times daily and after meals.

2004 WebMD, Inc. All rights reserved.


2 HEAD AND NECK

ACS Surgery: Principles and Practice


4 ORAL CAVITY PROCEDURES 6
OPERATIVE TECHNIQUE

Step 1: Surgical Approach


Lesion

Figure 5 Resection of hard palate. An incision is made around


the lesion, with adequate margins maintained, the periosteum is
lifted off the bone, and the lesion is removed.
COMPLICATIONS

The most significant potential complication of hard palate resection is oral antral or oronasal fistula; careful tissue reconstruction
and the use of an obturator can prevent this complication.
Maxillectomy
OPERATIVE PLANNING

General anesthesia with muscle relaxation is essential for all types


of maxillectomy. Either orotracheal or nasotracheal intubation may
be appropriate, depending on the surgical approach. Skin incisions
should be marked before the endotracheal tube is taped in place to
avoid distortion of facial structures and skin lines. The patient
should be supine in a 20 reverse Trendelenburg position.The eyes
should be protected carefully (e.g., with a corneal shield or a temporary nylon tarsorrhaphy suture).
Radiographic evaluation plays a vital role in planning the surgical approach and determining the extent of resection required
[see Figure 6]. Lesions of the infrastructure of the maxilla can be
excised by means of partial maxillectomy via the transoral route.
More extensive lesions usually must be accessed via facial incisions in conjunction with the transoral approach.
In all cases, a dental consultation should be obtained preoperatively so that a dental impression can be taken and an obturator
fashioned for intraoperative use. Antibiotics should be given perioperatively and continued until nasal packing is removed.

In addition to the transoral approach, maxillectomy usually


requires exposure of the anterior face of the maxilla. There are
several options for achieving such exposure, including a WeberFerguson incision and midface degloving. Midface degloving has
the advantage of eliminating the need for visible facial incisions,
but it yields limited exposure in the ethmoid region. The choice
of surgical approach is determined by the extent of the planned
resection and by the preferences of the patient and the surgeon.
In the Weber-Ferguson approach, the first step is to mark the
path of the incision, which begins in the midline of the upper lip;
extends through the philtrum; curves around the nasal vestibule
and the ala; continues upward along the lateral nasal wall, just
medial to the junction of the nasal sidewall and the cheek; and
ends near the medial canthus. For added exposure in the ethmoid
region, a Lynch extension, in which the incision is continued
superiorly up to the medial eyebrow, may be performed. Alternatively, the Weber-Ferguson incision may be continued laterally
in the subciliary crease along the inferior eyelid to the lateral canthus of the eye; this extension yields added exposure of the posterolateral aspect of the maxilla.
The skin incisions should initially be made with a scalpel and
then continued with an electrocautery. The upper lip is divided
through its full thickness, and the incision is continued in the gingivolabial sulcus laterally until the posterolateral aspect of the
sinus is exposed. When possible, the infraorbital nerve is identified and preserved. The soft tissues are elevated from the anterior wall of the maxillary sinus; if access to the pterygomaxillary fissure is desired, elevation should be continued up to the zygoma.
In a midface degloving, the skin of the lower face and nose is
mobilized and retracted superiorly. A standard transfixion incision is made, transecting the membranous septum. Intercartilaginous incisions are then made bilaterally and connected to the
transfixion incision.The incision is then continued laterally along
the cephalic border of the lower lateral cartilage and across the
floor of the nose. To prevent stenosis, a small Z-plasty [see 3:7
Surface Reconstruction Procedures] or triangle is incised medially
just before the transfixion incision is joined. The soft tissues are
elevated over the nasal dorsum and the nasal tip with Joseph scissors. An incision is made in the gingivolabial sulcus with the
monopolar cautery, and this incision is connected to the floor-ofnose incisions by means of gentle dissection. The soft tissues are
then elevated from the anterior maxilla as far as the infraorbital
rims and laterally as far as the zygoma.
Step 2: Resection
A Molt retractor is placed on the side opposite the side of the
planned excision and opened as wide as possible to expose the
hard palate and the alveolus.
The infraorbital rim should be preserved if it is possible to do
so safely. Often, a thin strip of the rim can be preserved even when
the rest of the bone must be resected. If the orbital floor must be
resected but the orbital contents can be preserved, the periorbita
can be dissected away from the bone of the orbital floor and preserved. If the orbital contents are involved, an orbital exenteration
must be performed in conjunction with the maxillectomy.
The cut along the infraorbital rim and superior anterior maxillary wall is made with a high-speed oscillating saw with a fine
blade. The level at which this superior cut is made is determined
by the extent of the resection. Lesions that are confined to the
alveolus or the palate and do not invade the maxilla typically can

2004 WebMD, Inc. All rights reserved.

ACS Surgery: Principles and Practice

2 HEAD AND NECK

4 ORAL CAVITY PROCEDURES 7

be removed by excising the infrastructure of the maxilla.The line


of transection is continued through the nasal process of the maxilla medially and downward through the piriform aperture. Laterally, the cut extends to the zygomatic process of the maxilla and
around the posterolateral aspect of the sinus.
If the pterygoid plates are to be preserved, they are cut free by
placing a curved osteotome along the posterior wall of the sinus and
sharply dividing the plates from the sinus wall. If the pterygoid
plates, part of the pterygoid musculature, or both are to be resected,
the soft tissue attachments are cut sharply with curved Mayo scissors once the entire maxillary specimen has been mobilized.
The line of transection in the maxillary alveolus can run
between two teeth if a suitable gap is evident. In the majority of
cases, however, it is advisable to extract a tooth and make the cut
through the extraction site. A power saw is used, and the cut is
connected to the transection line through the nasal process of the
maxilla and the piriform aperture. The hard palate mucosa is
then incised lateral to the proposed cut in the hard palate bone to
preserve a flap of mucosa that can be used to cover the raw cut
bony edge of the palate. This incision is made with a needle-tip
electrocautery and carried down to the bone of the hard palate.
It should extend from the maxillary tuberosity posteriorly to the
cut bone in the maxillary alveolus anteriorly, with care taken to
obtain adequate mucosal margins. The mucosa is elevated for a
short distance over the hard palate bone to create a short muco-

sal flap that is wrapped over the cut bony edge of the palate. The
mucosal cut is connected around the maxillary tuberosity to the
gingivolabial sulcus incision that was made earlier.
The hard palate is then cut with a power saw. Once all the bone
cuts are complete, an osteotome may be used to connect them if
necessary.The remaining soft tissue attachments are divided along
the posterior hard palate with curved Mayo scissors. The surgical
defect is packed to control bleeding. Bleeding from the internal
maxillary artery is controlled by ligatures or ligating clips.
Step 3: Reconstruction
All sharp spicules of bone are debrided.The flap of hard palate
mucosa is brought up over the cut bony edge of the palate and held
in place with several Vicryl sutures.The anterior and posterior cut
edges of the soft palate are reapproximated with absorbable sutures.
A split-thickness skin graft, 0.014 to 0.016 in. thick, is harvested and used to line the raw undersurface of the cheek flap.
The skin graft is sutured to the mucosal edge of the cheek flap
with 3-0 chromic sutures. Superiorly, the graft is not sutured but
draped into position and retained by a layer of Xeroform packing
and strip gauze coated with antibiotic ointment. Gentle pressure
is applied to the packing so that it conforms to the defect. The
previously fabricated dental obturator is placed to support the
packing and to close the oral cavity from the nasal cavity. In a
dentulous patient, the obturator may be wired to the remaining

Figure 6 Maxillectomy. Radiographic assessment helps determine the required extent of resection. Depicted
are (a) medial maxillectomy, (b) subtotal maxillectomy without orbital exenteration, and (c) total maxillectomy
with orbital exenteration.

2004 WebMD, Inc. All rights reserved.


2 HEAD AND NECK

ACS Surgery: Principles and Practice


4 ORAL CAVITY PROCEDURES 8

Figure 7 Mandibulectomy. A cheek flap is


created by making a lip-splitting incision
and extending it down to the level of the
thyrohyoid membrane, then laterally to the
mastoid along a skin crease.

teeth; in an edentulous patient, it may be temporarily fixed in


place with two screws placed in the remaining hard palate.
The skin incisions are closed in two layers, with interrupted
absorbable sutures used for the deep layers and nonabsorbable
monofilament sutures for the skin. If a lip-splitting incision was
made, care must be taken to ensure exact reapproximation of the
orbicularis oris and the vermilion border.
If the infraorbital rim was resected, it should be reconstructed to
yield good aesthetic results. A split calvarial bone graft may be used
for this purpose when there is adequate soft tissue coverage for the
bone grafts available.When soft tissue coverage is inadequate or the
orbital floor must be reconstructed, an osteocutaneous radial forearm or scapular flap may be employed with excellent results.
Alternative Procedure: Peroral Partial Maxillectomy
The oral cavity is exposed with cheek retractors. An incision is
made in the gingivobuccal sulcus and the mucosa of the hard
palate, with care taken to maintain adequate margins; a monopolar electrocautery, set to use the cutting current, is suitable for this
purpose. Incisions are made circumferentially through all the soft
tissues up to the anterior wall of the maxilla and the hard palate.
The infraorbital nerve should be preserved if it is not involved
with the disease process.
The cut in the hard palate mucosa should be made lateral to
the planned cuts in the hard palate bone to create a mucosal flap,
which will be used to cover the cut bony edge of the hard palate.
If necessary, teeth may be extracted to allow the surgeon to make
bone cuts through tooth sockets while preserving adjacent teeth.
The bone is cut with a high-speed power saw, and an osteotome
is used to divide any remaining bony attachments and deliver the
specimen. If the mucosa remaining in the maxillary antrum is not
diseased, it need not be removed.
A split-thickness skin graft, 0.014 to 0.016 in. thick, is harvested from the anterolateral thigh and used to reline the raw buccal

mucosa area. The graft is sutured to the cut edge of the buccal
mucosa with 4-0 chromic catgut. Xeroform and strip gauze coated with antibiotic ointment are gently packed into the defect to
secure the skin graft. The previously fabricated dental obturator
is wired to the remaining teeth to hold the packing in place.
TROUBLESHOOTING

If a lip-splitting incision is planned, lip contraction can be reduced and vermilion border realignment improved by employing a
stair-step lip incision and a Z-plasty. A single intraoperative steroid
dose reduces facial edema without compromising wound healing.
Retention of the obturator is aided by the band of scar tissue that
forms at the junction of the mucosa and the skin graft. Covering the
cut edge of the hard palate bone with mucosa eliminates pain
caused by pressure from the obturator on thinly covered bone.
If more than a small area of the floor of the orbit is resected, it
should be repaired to prevent enophthalmos. Epiphoria is uncommon; when it occurs, it is related to scarring of the nasolacrimal duct. Identifying the duct and transecting it obliquely should
reduce the incidence of this complication.
POSTOPERATIVE CARE

A nasogastric tube is placed at the end of the procedure. Many


patients are able to begin a liquid diet and advance to a soft diet
within a few days after operation. A soft diet should be continued
for at least 2 weeks. Oral rinses and flushes with normal saline or
half-strength hydrogen peroxide should be performed at least
four times daily and after meals.
The obturator and the packing may be removed from the cavity in 7 to 10 days. The obturator should be replaced to maintain
oral competence. The prosthodontist makes a final obturator
once healing is complete and the cavity has stabilized. Facial incisions are cleaned twice daily and coated with antibiotic ointment.
Facial sutures are removed 5 to 7 days after operation.

2004 WebMD, Inc. All rights reserved.


2 HEAD AND NECK
COMPLICATIONS

The main complications of maxillectomy are as follows:


1. Enophthalmos and hypophthalmos, which create a cosmetic deformity.
2. Infraorbital nerve injury, which results in anesthesia or paresthesia of the ipsilateral cheek and upper lip. On occasion, the
infraorbital nerve may have to be sacrificed as part of the
planned resection.
3. Epiphoria, caused by scarring of the nasolacrimal duct.
4. Difficult retention of the dental prosthesis, which can usually
be prevented by careful preoperative evaluation and appropriate choice of reconstructive method. In select cases, free tissue
reconstruction without a dental prosthesis may be optimal.
Mandibulectomy
OPERATIVE PLANNING

General anesthesia with muscle relaxation is essential for all


types of mandibulectomy. Either orotracheal or nasotracheal intubation is appropriate, depending on the surgical approach and the
extent of the planned resection. A tracheostomy should be performed whenever significant postoperative swelling or airway
compromise is anticipated. Skin incisions should be marked
before the endotracheal tube is taped in place.
Preoperative radiographic evaluation is essential for planning
the surgical approach and determining the extent of the proposed
resection. For lesions without radiographic or clinical evidence of
bone invasion, a marginal mandibulectomy is often appropriate.
This procedure may also be performed to obtain adequate surgical margins for lesions that are in close proximity to the mandible.
When the lesion is small, it is occasionally possible to perform
marginal mandibulectomy via the transoral route. For more extensive lesions and those that show evidence of bone invasion, a
segmental mandibulectomy is required.
The patient should be supine in a 20 reverse Trendelenburg
position. Perioperative antibiotics should be administered.

ACS Surgery: Principles and Practice


4 ORAL CAVITY PROCEDURES 9
the retromolar trigone, and it may lead to anesthesia of the lower
lip as a consequence of the need to divide both mental nerves.
Technical aspects of visor flap creation are summarized elsewhere
[see Anterior Glossectomy, Operative Technique, Step 1, above].
Step 2: Resection
If a plate is to be used in the reconstruction of the mandible, a
template and a reconstruction plate are shaped and conformed to
the mandible before resection. The segment of mandible to be
resected is marked. The plate is applied to the buccal cortex of
the mandible, and screw holes are predrilled in the mandible for
gauging of depth. The plate is then set aside until needed for
reconstruction.
Mucosal incisions are made around the lesion with the electrocautery, with care taken to maintain adequate surgical margins.The
mandibular segment to be removed is cut with a high-speed sagittal
saw.The lingual nerve and the hypoglossal nerve are preserved if possible. Muscle attachments to the resected mandibular segment are
sharply divided, allowing the surgical specimen to be delivered [see
Figure 8].

OPERATIVE TECHNIQUE

Step 1: Exposure
Wide exposure for access to primary tumors of the oral cavity
and the mandible may be achieved by means of either a lowercheek flap or a visor flap.The former is often preferable, in that it
allows resection of the primary and ipsilateral lymph nodes.
To create a lower-cheek flap, a lip-splitting incision is made
through the full thickness of the lower lip and carried down through
the chin tissues to the periosteum of the anterior mandible [see Figure
7].This incision may be made straight through the mental subunit
with a Z-plasty placed at the mental crease; alternatively, it may be
made around the mental subunit.The incision is continued vertically
to approximately the level of the thyrohyoid membrane, then extended laterally to the mastoid along a skin crease.The transverse component of the incision should be made at least two fingerbreadths below
the mandible to prevent injury to the marginal mandibular nerve.
The cheek flap is fully developed by incising the oral mucosa along
the gingivolabial sulcus while maintaining adequate surgical margins
around the lesion.The periosteum of the mandible is then elevated
and the cheek flap retracted to expose the mandible.
A visor flap [see Figure 3] has the advantage of not requiring a
lip-splitting incision, and it provides adequate exposure for lesions
of the anterior oral cavity. However, it is inadequate for exposing
lesions posterior to the middle third of the tongue or in the area of

Figure 8 Mandibulectomy. The segment to be removed is cut


with a high-speed saw, with care taken to preserve the lingual
and hypoglossal nerves if possible, and the muscle attachments
to the segment are sharply divided to free the surgical specimen.

2004 WebMD, Inc. All rights reserved.


2 HEAD AND NECK

ACS Surgery: Principles and Practice


4 ORAL CAVITY PROCEDURES 10

In some cases, only a marginal mandibulectomy of the lingual or


alveolar cortex of the mandible is necessary.The bone is cut with a
high-speed saw in such a way that the cuts are rounded off and lack
sharp angles, which are prone to fracturing. Once the bone cuts are
made, an osteotome may be used to free the specimen.
Step 3: Reconstruction
When a marginal mandibulectomy has been performed, a plate is
sometimes needed to support the mandible.This is especially likely
to be the case for a patient with a thin edentulous mandible, in which
the remaining bone cannot withstand the forces of mastication.
When the anterior mandible has been resected, it must be reconstructed with vascularized bone. Any of several free flaps may be
employed, depending on the tissue requirements for the planned reconstruction. Free tissue flaps from the fibula, the scapula, or the iliac crest can provide bone that is suitable for mandibular reconstruction, as well as soft tissue that is suitable for reconstruction of
accompanying mucosal and cutaneous defects.
After lateral mandibular resections, good results can be achieved
by using mandibular reconstruction plates with suitable soft tissue
reconstruction.There is a significant risk of plate failure, however,
especially in dentulous patients. In many cases, replacing the resected portion of the mandible with vascularized boneespecially if the
defect is longer than a few centimetersyields better long-term results than using a reconstruction plate alone.
POSTOPERATIVE CARE

A nasogastric tube is placed at the end of the surgical procedure;

most patients will need to be fed through this tube until their incisions are healed. A soft diet should be continued for 6 weeks. Oral
rinses and flushes with normal saline or half-strength hydrogen peroxide should be performed at least four times a day and after meals.
Facial incisions are cleaned twice a day and coated with antibiotic ointment. Facial sutures are removed 5 to 7 days after
operation.
TROUBLESHOOTING

Contouring the reconstruction plate to the mandible before


resecting the mandibular segment will prevent malocclusion and
enhance cosmetic results. Preserving the lingual nerve and the
hypoglossal nerve, when possible, will improve postoperative
swallowing and speech. The marginal mandibular nerve should
be identified and protected as well. If a lip-splitting incision is
used, performing a stair-step lip incision and a Z-plasty reduces
lip contraction and improves vermilion border realignment.
COMPLICATIONS

The main complications of mandibulectomy are as follows:


1. Malocclusion, caused by inaccurate repair of the resected
mandibular segment.
2. Plate failure or fracture, which can be reduced by reconstructing bony defects larger than 1 to 2 cm with revascularized bone.
3. Oral incompetence, caused by inadequate reconstruction of
anterior mandibular defects.

Selected Readings

Baurmash H: Submandibular salivary stones: current


management modalities. J Oral Maxillofac Surg 62:369,
2004
Brown JD:The midface degloving procedure for nasal,
sinus and nasopharyngeal tumors. Otolaryngol Clin
North Am 34:1095, 2001
Brown JS, Kalavrezos N, DSousa J, et al: Factors that
influence the method of mandibular resection in the
management of oral squamous cell carcinoma. Br J
Oral Maxillofac Surg 40:275, 2002
Galloway RH, Gross PD, Thompson SH, et al: Pathogenesis and treatment of ranula: report of three cases. J
Oral Maxillofac Surg 47:299, 1989
Hussain A, Hilmi OJ, Murray DP: Lateral rhinotomy
through nasal aesthetic subunits: improved cosmetic
outcome. J Laryngol Otol 116:703, 2002

Johnson JT, Leipzig B, Cummings CW: Management


of T1 carcinoma of the anterior aspect of the tongue.
Arch Otolaryngol 106:249, 1980
Lanier DM: Carcinoma of the hard palate. Surgery of
the Oral Cavity. Bailey BJ, Ed. Year Book Medical
Publishers, Chicago, 1989, p 163
Leipzig B, Cummings CW, Chung CT, et al: Carcinoma
of the anterior tongue. Ann Otol Rhinol Laryngol
91:94, 1982
Osguthorpe JD, Weisman RA: Medial maxillectomy
for lateral nasal neoplasms. Arch Otolaryngol Head
Neck Surg 117:751, 1991
Schramm VL, Myers EN, Sigler BA: Surgical management of early epidermoid carcinoma of the anterior
floor of the mouth. Laryngoscope 90:207, 1980

Spiro RH, Gerold FP, Strong EW: Mandibular


swing approach for oral and oropharyngeal tumors.
Head Neck 3:371, 1981
Stern SJ, Geopfert H, Clayman G, et al: Squamous cell
carcinoma of the maxillary sinus. Arch Otolaryngol
Head Neck Surg 119:964, 1993
Wald RM, Calcaterra TC: Lower alveolar carcinoma:
segmental v. marginal resection. Arch Otolaryngol
109:578, 1983

Acknowledgment
Figures 1 through 8

Alice Y. Chen.