Surgical Approaches for Oral Cavity Cancers

• A variety of surgical approaches:
  • Are available for resection of primary tumors of the oral cavity
• The choice of a particular approach will depend on factors such as:
  • The size and site of the primary tumor:
    • Anterior versus posterior
  • As well as its depth of invasion
  • Proximity to the mandible or maxilla
• Factors such as dentition, size of the oral aperture, trismus, and the size and mobility of the tongue:
  • Also influence selection of the surgical approach
• The various surgical approaches such as:
  • Peroral, mandibulotomy, lower cheek flap approach, visor flap approach, and upper cheek flap approach are shown in Figure
• The transoral approach has wider applications with technologic advances using:
  • Lasers (transoral laser microsurgery [TLM]) and robotics (transoral robotic surgery [TORS])

• When the peroral approach does not offer adequate exposure:
  • The visor flap or cheek flap approaches (upper or lower) become necessary
• The visor flap approach:
  • Provides sufficient exposure for anteriorly located lesions:
    • But is not satisfactory for tumors located in the posterior oral cavity
  • The benefit of this approach is that it avoids a lower lip–splitting incision:
    • But produces permanent numbness of the chin:
      • Because the mental nerves need to be transected for adequate mobilization of the flap
    • It also may cause sagging of the lower lip and drooling:
      • Because of a loss of support and sensation:
        • Thus its utility is limited
• The lower cheek flap approach:
  • Requires a midline lip–splitting incision that is continued laterally into the neck for exposure and neck dissection:
    • This approach provides excellent exposure for nearly all tumors of the oral cavity:
      • Except those of the upper gum and hard palate
  • Mandible resection (marginal or segmental) and reconstruction:
    • Require the lower cheek flap approach in most instances
• The lower cheek flap approach:
  • Is required for marginal or segmental mandibulectomy of tumors adjacent to the body of the mandible
• The upper cheek flap approach (the Weber-Ferguson incision and its modifications):
  • Is required for resection of larger tumors of the hard palate and upper alveolus:
    • Particularly if they are posteriorly located
• Access to larger tumors of the tongue, particularly those closer to the base of the tongue where the mandible is not involved:
  • Requires wider exposure for resection:
    • A mandibulotomy or mandibular osteotomy is an excellent mandible sparing surgical approach:
      • Designed to gain access to the oral cavity or oropharynx for resection of primary tumors otherwise not accessible through the open mouth or by the lower cheek flap approach (Figure)

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