Keywords
lip neoplasms/surgery, carcinoma, squamous cell/surgery, lip neoplasms/radiation therapy, lip/pathology
The lower lip is the most frequent site for cancers. Only 7% of lip cancers arise in the upper lip, and 4% arise at the oral commissure ( Fig. 7.1 ). Most cancers occur in the lower lip because compared with the upper lip, the projecting vermilion border of the lower lip receives more sun exposure. Other factors that contribute to the risk of lip cancer include alcohol and tobacco use, especially when direct contact with tobacco is present, as with pipe and cigar smoking.
Squamous cell carcinoma is the most common malignant tumor of the lips (95%). The site allocation and staging criteria for lip cancers have been recently revised. In the past the lips were included as one of the primary sites in the oral cavity; however, the clinical behavior of most lip cancers is closer to that of skin cancers than it is to that of the oral mucosa. Therefore in the most recent revision of the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (UICC) staging system (eighth edition), the lips are divided in two separate regions ( Fig. 7.2 ). The visible vermilion border covered by keratinizing squamous epithelium, or the “dry vermilion,” is staged according to the criteria for skin cancers. The lip mucosa that is in contact with each other (the lower and upper lip) and extending further on the labial mucosa, also called the “wet vermilion,” or mucusola lips containing minor salivary glands is staged as one of the sites in the oral cavity ( Fig. 7.3 ). Basal cell carcinomas, melanomas, and minor salivary gland cancers represent the next most common primary neoplasms of the lip. Soft tissue sarcomas are exceedingly rare.
Evaluation
Clinically, epithelial cancers of the visible vermilion border of the lip have a characteristic exophytic cauliflower-like or ulcerated, endophytic nodular appearance. They have varying degrees of infiltration of the underlying musculature and invasion of the overlying skin and/or labial mucosa ( Fig. 7.4 ). Minor salivary gland tumors of the lip present as slow-growing nodular masses that may be subcutaneous or submucosal ( Fig. 7.5 ). Soft tissue tumors also present as a subcutaneous or submucosal mass of varying consistency. Hemangiomas and lymphangiomas are characteristically soft and spongy in nature and usually manifest at an early age ( Fig. 7.6 ). Melanomas of the vermilion border or mucosa of the lips are usually pigmented but also may be amelanotic ( Fig. 7.7 ).
The lesion may involve a portion of the lower lip, the entire lower lip, the commissure of the oral cavity, or both the upper and lower lips ( Figs. 7.8 through 7.11 ). Many well-differentiated squamous carcinomas are associated with varying degrees of hyperkeratosis and leukoplakia of the vermilion border. These pathologic changes also should be considered part of the lesion in surgical treatment planning.
The recently revised staging criteria for primary cancer of the external/visible/dry vermilion border of the lip are similar to those for skin cancers, and those for the nonvisible/wet vermilion and labial mucosa are similar to those for mucosal cancers of the oral cavity (AJCC/UICC eighth edition Staging Manual). Most patients present with early-stage tumors. Only 10% of patients present with clinically palpable cervical lymph node metastasis. The stage distribution of patients with carcinoma of the lip at diagnosis is shown in Fig. 7.12 .
Imaging
Radiographic workup of early-stage tumors of the lips is usually not required. However, advanced tumors of the lips, particularly those that are adherent to the adjacent bone, require radiographic evaluation to assess the extent of bone invasion. A high index of suspicion for invasion of the inferior alveolar nerve should be maintained for patients with numbness of the skin of the chin and lower lip. This phenomenon is most common in persons with neurotropic tumors, including adenoid cystic carcinoma, melanoma, and squamous carcinoma ( Fig. 7.13 ). Therefore detailed radiographic evaluation of the mandible is vitally important in treatment planning. Panoramic radiographs of the mandible provide a good initial assessment of the bone and mandibular canal ( Fig. 7.14 ). However, more detailed studies require a computed tomography (CT) scan or magnetic resonance imaging (MRI) for accurate delineation of the extent of bone invasion and for evaluation of invasion of the inferior alveolar canal or for demonstration of perineural invasion ( Fig. 7.15 ). MRI is particularly helpful in assessing bone invasion through alteration in the bone marrow signal, whereby the normal fatty signal is replaced by grayish tumor infiltration ( Fig. 7.16 ). Perineural invasion is demonstrated by enhancement of the inferior alveolar nerve on T2-weighted images. It also may show tumor extension through the foramen ovale into the middle cranial fossa.
Treatment
The obvious goal of therapy is long-term control of cancer with preservation of competency of the oral cavity and maintenance of aesthetic appearance of the lips. Small primary tumors of the lower or upper lip are very well controlled by either surgical excision or irradiation. Surgical excision for a small lesion is expeditious and leaves essentially no aesthetic or functional debility, even in the long term. In contrast, long-term sequelae of radiotherapy to the lip include atrophy of the skin and underlying musculature, resulting in indentation at the site of the primary tumor. Larger lesions require planned surgical resection with reconstruction, keeping in mind the aesthetics, function, and preservation of the nerve and blood supply to the remaining musculature of the lips to maintain facial expression. Although the lips have a rich lymphatic drainage to regional lymph nodes, metastatic dissemination is uncommon in early-stage tumors. Therefore elective treatment of regional lymph nodes is considered for only very advanced primary tumors.
Factors Affecting Choice of Treatment
The factors that affect the selection of initial therapy are related to the tumor and the patient ( Box 7.1 ). Tumor factors include the T stage (particularly bone invasion in T4 tumors), histology, extent of dysplastic vermilion surface, depth of infiltration of the labial musculature, and involvement of the oral commissure.
Tumor factors
Size (T-stage) of the primary tumor
Histology of the tumor
Extent of lip resection necessary
Availability of local tissues for reconstruction
Anticipated aesthetic and functional outcome of reconstructive surgery
Patient factors
Age
General medical condition
Compliance by the patient
Cost and convenience of treatment
In planning surgical treatment, preservation or restoration of oral competency and the size of the mouth opening as well as aesthetic appearance are crucial factors. These factors affect the ability to eat, clarity of speech, and facial expression. Small superficial lesions are easily managed by a simple wedge excision with primary repair, with excellent preservation of lip function and aesthetic appearance. Larger lesions of the lip can pose a reconstructive challenge. In general, local flaps from adjacent skin and soft tissues and the opposite lip often provide sufficient tissue for an excellent functional and aesthetic outcome. More extensive lesions that involve a large volume of lip or invasion of the underlying bone often require a composite resection with reconstruction using a composite free flap.
Patient-related factors include the general medical condition of the patient with regard to the safety of anesthesia and surgery, particularly when a major composite resection with free flap reconstruction is required. The age of the patient is an important factor in considering surgical treatment. Unlike young patients, older patients generally have lax lips, which permit primary closure or reconstruction with local flaps.
Radiation Therapy
Definitive radiotherapy is equally effective as surgery in local control of early-stage epithelial malignancies of the lips such as basal cell and squamous cell carcinomas. However, radiotherapy is not effective in the treatment of melanoma, minor salivary gland carcinomas, and soft tissue tumors. In planning radiotherapy as definitive treatment, the status of adjacent dentition and the age of the patient are important considerations.
External beam radiation therapy with electrons generally is used for lesions confined to the skin and soft tissues of the lips. A therapeutic dose of 6600 cGy is delivered in conventional fractionation of 200 cGy per day in 33 treatments. Elective irradiation of regional lymph nodes is not recommended in early-stage tumors (T1 and T2). On the other hand, interstitial irradiation alone with iridium-192 implant also has been shown to be equally effective in local control of tumors of limited extent ( Figs. 7.17 through 7.19 ). In spite of excellent local control, irradiation is generally not recommended as the preferred treatment because of the long-term sequelae of radiotherapy. Skin dryness, soft tissue atrophy, and indentation of the vermilion border at the site of the primary tumor often result in a suboptimal long-term outcome. Therefore radiotherapy is recommended only in select situations.
Surgical Treatment
Surgical Anatomy
The upper lip is formed by the fusion of lateral maxillary processes and a central nasofrontal process. This embryonic fusion leads to the presence of a central midline mass with two lateral larger segments. Because of the separation of the lateral segments, contralateral neck metastasis from upper lip cancer is exceedingly rare. On the other hand, the lower lip is formed by the fusion of two lateral mandibular processes in the midline, which puts lower lip cancers at increased risk of contralateral neck metastasis. Blood supply to the lips is provided by the superior and inferior labial arteries and branches of the facial artery on each side. The labial arteries form an arcade around the oral cavity in such a way that lesions in the lateral aspect of the lip receive blood supply both from its medial and lateral regions. Sensory supply to the skin and the vermilion border of the upper and lower lips is provided by the maxillary and mandibular divisions of the trigeminal nerve, respectively. Oral competency is the primary function of the orbicularis oris muscle, which also works in concert with the levators and depressors of the commissures to provide facial expression in addition to their contribution to oral competency. In surgical treatment planning, restoration of the purse-string function of the orbicularis oris muscle is crucial for maintaining oral competency. Muscular control of the orbicularis oris, the levators, and the depressors of the oral commissure is provided by the facial nerve. Lymphatic drainage of the lips is well defined and follows a predictable pattern for metastatic dissemination. Lesions of the lateral aspect of the upper lip first drain to buccal, periparotid, and prevascular facial lymph nodes overlying the body of the mandible. Lymph node metastasis occurs at level I in the submandibular triangle and then into the deep jugular chain. Lymphatics of the lower lip initially drain to lymph nodes at level I in the submental (Ia) and submandibular (Ib) regions and to the prevascular facial lymph nodes overlying the body of the mandible. Lymphatics of the lower lip often cross the midline and drain to the contralateral lymph nodes. Therefore bilateral metastasis to level I lymph nodes is not uncommon. Subsequent dissemination of metastatic disease occurs to deep jugular lymph nodes at levels II and III. Metastatic dissemination to level IV and level V is exceedingly rare.
Surgical Approaches
The approaches for surgical resection of neoplasms of the lips are categorized by the methods used to restore the surgical defect. Thus they are (1) resection and primary closure, (2) resection and reconstruction with local flaps, and (3) resection and reconstruction with free tissue transfer. Limited lesions (T1 and T2) of the upper or lower lip are easily treated with a wedge resection and repaired with primary closure, particularly in older patients. Early stage lesions of the oral commissure require special consideration in reconstruction to avoid a rounded commissure. Lesions that create a surgical defect not suitable for primary closure by virtue of size or location require reconstruction with local flaps from adjacent skin and soft tissues or the opposing lip. Larger defects of the upper lip, lower lip, or commissure and composite defects, including the underlying mandible or maxilla, require complex reconstruction with composite free tissue transfer.
Procedures
Lower Lip
V Excision of the Lower Lip.
Small superficial lesions involving the vermilion border and the underlying musculature of the lip are easily amenable to an elliptical excision that can be performed under local anesthesia with very gratifying aesthetic and functional results. It is important to remember that the natural skin creases on the vermilion border are in a radial direction along the circumference of the mouth ( Fig. 7.20 ). Excision is therefore planned accordingly. The resulting scar virtually merges with the natural skin lines, resulting in a very pleasing aesthetic result. The patient shown in Fig. 7.21 has a squamous carcinoma involving the cutaneous surface of the lower lip with deep infiltration of the underlying musculature extending up to the submucosal plane on the labial aspect of the lower lip. A simple through-and-through V excision of the lower lip is planned to excise the lesion in a three-dimensional fashion ( Fig. 7.22 ). The skin incision is performed with a scalpel to maintain sharp cut edges of the skin for accurate reapproximation of the vermilion border to acheive an acceptable aesthetic result. The remainder of the operation is completed with use of an electrocautery to minimize blood loss. The inferior labial artery must be carefully identified during excision and ligated. A through-and-through surgical defect is thus created ( Fig. 7.23 ). Reapproximation of the surgical defect requires meticulous alignment of the vermilion border. A 5-0 nylon suture is placed initially at the mucocutaneous junction of the vermilion border, accurately aligning the vermilion edge. With traction on this suture, 3-0 chromic catgut interrupted sutures are placed in the subcutaneous tissue and muscular layer to approximate the orbicularis oris muscle and subcutaneous soft tissues. After this reapproximation, mucosal closure with interrupted 3-0 chromic catgut sutures starting from the gingivolabial sulcus up to the vermilion edge is performed. Finally, 5-0 nylon interrupted sutures are taken for the skin and the vermilion border. Accurate alignment of the vermilion edge results in a very pleasing aesthetic appearance ( Fig. 7.24 ).
Lip Shave.
The most important indications for a lip shave operation are areas of leukoplakia with keratosis and in situ or superficially invasive carcinomas. The entire vermilion surface of the lip may require excision for these entities. The operative procedure is likely to be successful if the diseased areas of the lip are confined to the wet and dry vermilion surfaces of the lip on the vermilion border and are not of an infiltrating nature. Small and superficial limited regions of the vermilion mucosa can be excised by a lip shave procedure under local anesthesia. However, extensive lip shave procedures require administration of a general anesthetic to accomplish a satisfactory surgical resection with appropriate reconstruction using a bipedicled labial mucosal flap for restoration of the vermilion border. The patient shown in Fig. 7.25 presented with a hyperkeratotic superficial infiltrating squamous cell carcinoma involving nearly 80% of the vermilion border of the lower lip. Palpation revealed that the lesion had essentially no infiltrative component in the underlying musculature. An extensive lip shave procedure with resection of only a small amount of lip musculature is planned. The surgical procedure is performed under general anesthesia through a nasotracheal tube. Adequate excision of the vermilion border is performed through an extensive lip shave procedure in a monobloc fashion. The margins of the surgical defect must be checked by frozen section analysis to ensure adequate resection.
The surgical defect is shown in Fig. 7.26 . The mucosa of the lower lip is now mobilized all the way up to the attached gingivolabial sulcus, keeping its blood supply intact through its lateral pedicles ( Fig. 7.27 ). Thus the entire labial mucosa is mobilized throughout the extent of the lower lip in a bipedicled flap fashion. A horizontal relaxing incision is now placed in the gingivolabial sulcus. This bipedicled mucosal flap is now advanced anteriorly and externally to cover the surgical defect appropriately. Interrupted nonabsorbable sutures are used to approximate the labial mucosa to the cutaneous margin of the surgical defect. Accurate alignment of the mucosa to the remaining vermilion border is vitally important to restore the anatomic configuration of the reconstructed lower lip ( Fig. 7.28 ). The mucosal defect in the gingivolabial sulcus created by advancement of the bipedicled flap is left open to heal by secondary intention. The appearance of the patient approximately 3 months after surgery shows quite satisfactory primary healing of the lower lip with restoration of the aesthetic appearance and preservation of the functional competency of the lower lip and the oral cavity ( Fig. 7.29 ).
Lip Shave Operation With V Excision for Carcinoma of the Lower Lip.
The patient shown in Fig. 7.30 has a nodular infiltrating squamous cell carcinoma of the vermilion border of the lower lip on the right-hand side measuring approximately 1.5 cm on its surface. He also has diffuse areas of leukoplakia involving the vermilion border of most of the lower lip. Except for the palpable nodule at the site of the infiltrating cancer, the remaining lesion is very superficial.
Surgical excision of this lesion will require a V excision at the site of the palpable nodule in conjunction with a lip shave procedure for excision of the vermilion border of the lower lip. The outline of the incision is shown in Fig. 7.31 . The operation can be performed under local or general anesthesia. If a local anesthetic is used, the entire lower lip is infiltrated with 1% lidocaine with epinephrine (adrenaline) 1:100,000 solution. If, however, local anesthesia is used, then the surgical incision must be marked with a skin marking pen before infiltration of the local anesthetic. On the other hand general anesthetic is usually preferred, because it allows more satisfactory control of the operative procedure and avoids any distortion in the configuration of the mucocutaneous junction of the lip. The operation begins with the lip shave part of the procedure first. A skin incision is made at the mucocutaneous junction of the lower lip beginning on the left-hand side of the patient and up to the edge of the proposed V excision. A similar incision is made on the mucosal aspect of the lower lip following the outline previously marked. Brisk bleeding from this area should be expected, and therefore use of suction with a Frazier suction tip is preferable for a dry field. A toothed Adson forceps is then used to grasp the tip of the surgical specimen on the left side, and the remainder of the dissection proceeds with the use of fine needle tip electrocautery with coagulating current ( Fig. 7.32 ). Dissection now proceeds in a relatively superficial plane, taking as little of the underlying musculature as possible, but ensuring that no “buttonholes” are made through the mucosa of the surgical specimen.
As the specimen is mobilized toward the right-hand side, dissection continues, keeping uniform thickness of the excised specimen until the edge of the V excision is reached ( Fig. 7.33 ). Complete hemostasis is secured at this stage of the operation by electrocoagulating the bleeding points, which usually are from the dermal and the mucosal edges of the surgical defect.
At this point a skin incision is made with a number 15 scalpel along the previously marked V and is carried across to the right-hand side near the commissure of the mouth, completing the entire length of the incision on the labial mucosa posteriorly ( Fig. 7.34 ). The remainder of the surgical excision is then completed, again using electrocautery. At the site of the V, a through-and-through wedge of the lower lip is excised, with the underlying musculature and the overlying mucosa posteriorly. Usually the labial artery can be easily identified, clamped, divided, and ligated to minimize brisk hemorrhage from the vessel. Pulling on the specimen must be avoided, because if it is pulled too hard during the dissection, unnecessary amounts of the labial musculature will be resected, resulting in a notched deformity at the site of the surgical excision.
The surgical defect resulting from this excision is shown in Fig. 7.35 . The labial artery requires ligation at both ends of the defect of the V excision. The adequacy of the surgical excision is confirmed by frozen section examination of the margins. Meticulous attention should be given to absolute hemostasis; otherwise, bleeding and a hematoma will develop in the postoperative period.
Closure of the surgical defect begins with a fine nylon suture taken through the vermilion edge of the skin defect at both ends of the V excision defect of the lower lip. The suture is placed and held tight, but it is not tied. This process will allow accurate approximation of the vermilion edges to avoid a notched deformity or inaccurate approximation of the vermilion border of the reconstructed lower lip. Traction is now applied to the ends of this skin suture to allow both sides of the surgical defect to collapse to permit accurate placement of the muscular sutures. Once the muscular layer is closed, dynamic reconstruction for maintenance of competency of the oral cavity is accomplished ( Fig. 7.36 ).
Attention is now focused on mobilization of the labial mucosa, which will be used to reconstruct the new vermilion surface ( Fig. 7.37 ). The oral cavity is opened generously, and large Richardson retractors are placed at the oral commissure on both sides to expose the gingivolabial sulcus. Electrocautery is used to place a relaxing incision in the gingivolabial sulcus as shown. The labial mucosa is placed under tension by retracting it, while the incision in the gingivolabial sulcus is made with electrocautery to allow easy separation of the mucosa covering the gum and the lower lip.
An Adson forceps is now used to grasp the upper edge of the labial mucosa, and submucosal dissection of this bipedicled, labial mucosal flap is undertaken with use of electrocautery ( Fig. 7.38 ). The dissection technique in the submucosal plane requires meticulous attention; otherwise, buttonholes will occur in the mucosa if the flap is too thin, or unnecessary musculature of the lower lip will be taken if the flap is too thick. The accurate plane of dissection is such that some minor salivary gland tissue remains on the mucosal flap while the musculature remains intact ( Fig. 7.39 ). The entire flap is mobilized through the length of the incision in the mucosa of the gingivolabial sulcus; thus this becomes a bipedicled, labial, mucosal flap of the lower lip.
