COMPARISON OF VISOR FLAP APPROACH WITH LOWER LIP SPLIT APPROACH IN RESECTION OF ORAL CANCERS

Abstract

BACKGROUND: In India head and neck cancers account for 30-35% of all malignancies, and about 50% of these are oral cancers. . Buccal mucosa and lower gingivobuccal sulcus are usually affected in our patients due to the habit of tobacco quid chewing. Early cancers of the oral cavity can be resected by both Lip split and without splitting the lower lip by raising the soft tissues of the face off the mandible like a visor thereby accessing the oral cavity -Visor approach. Anteriorly placed oral cancers can also be addressed by visor approach , thereby avoiding the conventional lip split and providing a better cosmetic result. Also, in tumors present close to the angle of mouth, it is advisable to avoid splitting the lip as it may result in avascular necrosis post operatively. Lip-split approach for oral cancers can compromise vascularity of lower lip and can predispose to lip necrosis when lip split approach is used during composite resection. So, surgical approaches that preserve function, minimize complications, maximize cosmetic outcome should be utilized appropriately in patients depending on size and site of the tumor. The Visor flap approach has been tried for accessing oral cavity tumors without splitting the lower lip to reduce morbidity and preserve aesthetics. In this technique, the soft tissues of the face are elevated along with the neck flap without splitting the lower lip (like the visor of a helmet).Visor flap can also be used when a microvascular free tissue transfer is done for the reconstruction of the surgical defect. xiii In our study we intend to compare resection of lateral tumors of oral cavity by conventional lower lip split approach and visor approach avoiding the lip split with regard to the following variables: time taken for surgery, adequacy of exposure of primary tumour and resection margins, adequacy of access for reconstruction, and post-operative complications if any. OBJECTIVES:  To perform a neck dissection and lower lip split approach for composite resection of oral cavity malignancy in 33 patients (Group A) and document the time taken for surgery, adequacy of exposure of primary tumour and resection margins, adequacy of access for reconstruction, and post-operative complications if any.  To perform a neck dissection and Visor flap approach for composite resection of oral cavity malignancy in 33 patients (Group B) and document the time taken for surgery, adequacy of exposure of primary tumour and resection margins, adequacy of access for reconstruction, and post-operative complications if any.  To compare visor flap approach with lower lip split approach with regard to the above variables. METHODOLOGY: Following an informed written consent 66 patients, after fulfilling the inclusion criteria of the study, undergoing surgery for T2 and T3 staged oral cavity cancers under Department of Otorhinolaryngology and Head and Neck Surgery of R.L.Jalappa Hospital and Research , Tamaka, Kolar from December 2018 till May 2020 will be included in this study. The patients will be segregated into two groups. Following a neck dissection for all these patients, Group A will undergo composite xiv resection of oral cancer by lip split approach and Group B will undergo composite resection of oral cancer by visor approach without lower lip split. RESULTS: Our study included T2(58%)and T3 (42%) staged squamous cell carcinoma of the oral cavity. The T4 tumors were excluded to avoid the risk of positive bone margin in visor flap approach which was relatively new to this institution. In our study, majority of the patients were elderly women in the age group of 46-60 years. This can be explained by the fact that the women in this rural area are addicted to chewable carcinogens like tobacco quid(sometimes kept overnight in the cheek), areca nut, betel leaves etc while the men are more addicted to smoking tobacco. 56% of our patients had no palpable lymph nodes and 44% of patients presented with palpable neck nodes. The nodal status did not affect the approach or resection of the primary tumor in both groups. 75.8% patients in Group A and 87.9% patients in Group B showed well differentiated tumour on histopathology. In our study, there was no significant difference in both the two groups with respect to adequacy of exposure. However, in group B, we noticed an inadequate exposure in 3 cases(9%). In our study, we have used Pectoralis major myocutaneous flap, supraclavicular flap , submental flap and radial forearm free flap for reconstruction of the defect following excision of the primary tumour. However Bulky PMMC flaps owed to difficult access for reconstruction as seen in one patient in Group A and 3 patients in Group B. Compared to Group A , we have used more of supraclavicular flap in Group B to aid in better reconstruction as the exposure is limited in visor xv approach. The mean time taken for excision of primary tumor and reconstruction in Group B was more than in Group B . Close margins were marginally more frequent in Group A -particularly anterior margin. However other margins in both groups were comparable. Salivary leak was the most common complication in both the groups. CONCLUSION: 1. Oral cancer has a high prevalence in developing countries and requires aggressive multimodality treatment resulting in functional and aesthetic deficits. 2. With the improving diagnostic facilities and therapeutic options, head and neck surgeons are faced with the challenge of minimizing morbidity and ensuring better quality of life while simultaneously improving the loco regional control. 3. The midline lower lip split to access the oral cavity malignancies for surgical resection remains the gold standard but also has limitations with regard to aesthetic appearance and vascularity of lip, particulary in lesions situated close to oral commissure. 4. A visor flap approach (non lip-split) for resection of oral cancers and few of its modifications provide a better aesthetic appearance and competence of oral commissure. And also ensures better vascularity for lower lip. 5. The frequency of surgical complications encountered both by lip split approach and visor flap approach is almost similar. However the operating time may be longer and access for suturing a bulky flap for reconstruction may be limited. 6. Having been used less frequently few surgeons may find the visor flap approach more time consuming and difficult. However this is a subjective perception and can be minimized as more is gained in this approached. xvi 7. The adequacy of resected margins and outcome of surgery with regards to healing remains similar between the two approaches-lower lip split and visor flap approach. 8. Visor flap approach for resection of oral malignancies is a reliable and effective option especially if the tumor is situated to close to oral commissure.