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👉A lateral mandibulotomy has several disadvantages:

• First, the muscular pull on the two segments of the mandible is unequal:
  • Putting the mandibulotomy site under significant stress and causing a delay in healing:
    • For this reason, intermaxillary fixation may be required
• Second, the ability to gain access to the suture line to maintain cleanliness following surgery in the oral cavity is hampered as a result of intermaxillary fixation:
  • Leading to poor oral hygiene and the potential risk for sepsis of the suture line
• In addition, a lateral mandibulotomy poses several anatomic disadvantages:
  • Leading to denervation of the teeth distal to the mandibulotomy site and the skin of the chin:
    • As a result of transection of the inferior alveolar nerve
• A lateral mandibulotomy also causes devascularization of the distal teeth and the distal segment of the mandible:
  • From its endosteal blood supply
• The exposure provided by a lateral mandibulotomy is:
  • Limited
• If the patient needs postoperative radiation therapy:
  • The mandibulotomy site is directly within the lateral portal of radiation therapy:
    • Leading to delayed healing and complications at the site of the mandibulotomy

👉For these reasons, a lateral mandibulotomy is not recommended

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• 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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• 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
• Key Aspects of the Lower Cheek Flap Approach:
  • Technique: 
    • The incision starts by dividing the lower lip in the midline, extending down the chin to the symphysis of the mandible
    • It then continues down to the level of the thyrohyoid membrane and turns into the neck, usually following a skin crease
  • Exposure: 
    • The flap is raised in the subplatysmal plane, allowing broad access to the mandibular arch, oral diaphragm, and floor of the mouth
  • Reconstruction / Closure: 
    • The incision is closed with special attention to the vermilion border of the lip to minimize deformity
    • The mylohyoid muscle and orbicularis oris muscle are reapproximated
  • Indications: 
    • Used for advanced oral cancers (T3 to T4) where broad exposure is required:
      • Particularly for tumors involving the gingivobuccal sulcus or anterior tongue
    • Disadvantages / Complications:
      • Anesthesia: 
        • Sacrifices the mental nerve, resulting in lower lip numbness
      • Nerve Damage: 
        • Risk of injury to the marginal mandibular nerve
      • Cosmesis: 
        • The lip-splitting incision can create a visible scar
• Comparison to Other Approaches:
  • Visor Flap: 
    • An alternative, similar approach that avoids the lower lip-splitting incision but may provide less exposure
  • Mandibulotomy: 
    • Often used for more posterior oral cavity or oropharynx tumors to allow access by dividing the jaw
  • Transoral Approach: 
    • Preferred for smaller, localized tumors, avoiding facial incisions, but often insufficient for advanced disease
• This approach is highly effective for large tumors when adequate, wide margins are essential

• To determine the need and extent of mandible resection:
  • It is essential to understand the pathway by which oral cancers invade the mandible
• Primary carcinomas of the lip, buccal mucosa, tongue, and floor of the mouth:
  • Extend along the surface mucosa and the submucosal soft tissues:
    • To approach the attached labial, buccal, or lingual gingiva
  • From this point:
    • The tumor does not extend directly through intact periosteum and cortical bone toward the cancellous part of the mandible:
      • Because the periosteum acts as a significant protective barrier
  • Instead:
    • The tumor advances from the attached gingiva toward the alveolus:
      • In patients with teeth:
        • The tumor extends through the dental socket into the cancellous part of the bone and invades the mandible in that fashion (Figure)

• In edentulous patients:
  • The tumor extends up to the alveolar process and then infiltrates the dental pores in the alveolar ridge and extends to the cancellous part of the mandible (Figure)

 

• Thus even in patients with early invasion of the mandible:
  • A marginal mandibulectomy is feasible because the cortical part of the mandible inferior to the roots of the teeth:
    • Remains uninvolved and can be safely spared
• In edentulous patients, however, the feasibility of marginal mandibulectomy depends on the vertical height of the body of the mandible:
  • With aging, the alveolar process recedes and the mandibular canal comes closer to the surface of the alveolar process:
    • As shown in the Figure, the resorption of the alveolar process eventually leads to a “pipestem” mandible in elderly patients

• The ability to perform a satisfactory marginal mandibulectomy in such patients is almost impossible:
  • Because the probability of iatrogenic fracture or postsurgical spontaneous fracture of the remaining portion of the mandible is very high:
    • Similarly, in patients who have received previous radiotherapy:
      • A marginal mandibulectomy should be performed with extreme caution:
        • The probability of pathological fracture at the site of the marginal mandibulectomy in such patients is very high
• When the tumor extends to involve the cancellous part of the mandible:
  • A segmental mandibulectomy must be performed
  • A segmental mandibulectomy also may be required in patients with massive primary tumors with significant soft tissue disease in the proximity of the mandible

• Rodrigo Arrangoiz MS, MD, FACS, FSSO is an Assistant Professor at New York Medical College School of Medicine Division of Surgical Oncology at Mount Sinai Medical Center
• He is first author on some publications on oral cavity cancer:
  • Oral Tongue Cancer: Literature Review and Current Management
    • https://www.oatext.com/pdf/CRR-2-153.pdf
  • Understand Cancer: Research and Treatment Oral Cavity Cancer: Literature Review and Current Management.
    • https://www.researchgate.net/publication/303366031_Understand_Cancer_Research_and_Treatment_Oral_Cavity_Cancer_Literature_Review_and_Current_Management

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz #CancerSurgeon #HeadandNeckSurgeon #SurgicalOncologist #MountSinaiMedicalCenter #MSMC #Miami #Mexico #BramanComprehensiveCancerCenter #BCCC

• The oral cavity represents the entrance to the upper aerodigestive tract:
  • Which begins at the lips and ends at the anterior surface of the faucial arch
  • It is lined by:
    • Squamous epithelium:
      • With interspersed minor salivary glands
• The oral cavity also contains the:
  • Dentoalveolar structures:
    • With the upper and lower dentition
• The oral cavity is continuously exposed to inhaled and ingested carcinogens:
  • Thus it is the most common site for the origin of malignant epithelial neoplasms in the head and neck region
  • Known carcinogens for oral cavity carcinoma include:
    • Those present in tobacco, alcohol, and betel nuts
    • The association of human papilloma virus with oral cancer:
      • Is not as well established as in oropharyngeal cancers
• Primary tumors of the oral cavity may arise from the:
  • Surface epithelium (most common)
  • Minor salivary glands
  • Submucosal soft tissues
  • Lesions of dentoalveolar origin:
    • Representing a unique group of neoplasms and cysts
• The various anatomic sites within the oral cavity as described by the American Joint Committee on Cancer (AJCC) and International Union Against Cancer (UICC) staging system are shown below:

• More than 90% of malignant tumors in the oral cavity are:
  • Squamous cell carcinomas:
    • The remainder are:
      • Minor salivary gland carcinomas and other rare tumors
• Most patients with cancer in the oral cavity are men:
  • Although the incidence of tongue cancer in women in the United States has progressively increased over the past several decades
• In the Western world:
  • The tongue (> 50% of cases) and floor of the mouth:
    • Are the most common sites of origin for primary squamous cell carcinomas in the oral cavity:
      • However, the retromolar trigone and buccal mucosa:
        • Are the most frequently encountered primary sites in areas of the world where chewing of tobacco and / or betel nuts is common
• The site distribution of various primary cancers in the oral cavity in the United States is shown bowls:

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– The goals of treatment of cancer of the oral cavity are:

• Cure of the cancer

• Preservation or restoration of:

  • Speech, mastication, swallowing, and external appearance

• Minimization of the sequelae of treatment such as:

  • Dental decay, osteonecrosis of the mandible, and trismus

• Awareness of the risk of subsequent primary tumors and their management

– Surgery and radiotherapy can be used as a single modality or in combination for the treatment of cancer of the oral cavity

– Treatment Approaches:

• In general, early-stage (stage I or II) head and neck tumors:

  • May be treated using a single modality (surgery or radiotherapy):

    • Whereas advanced disease (stage III or IV) frequently benefits from multimodality therapy

  • The best therapeutic approach for the primary tumor depends on the anatomic site

  • Most neck disease can be treated equally well with surgery or radiation:

    • Thus the modality chosen to treat the neck is based on which modality is selected for the primary

  • When the primary tumor is treated with irradiation:

    • The regional lymphatics “at-risk” are incorporated into the treatment fields

  • Neck dissections should remain standardized (ie, complete anatomic dissections, as opposed to “berry picking” or random biopsy) in these settings to avoid incomplete surgery

Rodrigo ArrangoizSinai Medical Center in Miami, Florida:

He is first author on some publications on oral cavity cancer:

• Oral Tongue Cancer: Literature Review and Current Management 

  • https://www.oatext.com/pdf/CRR-2-153.pdf

• Understand Cancer: Research and Treatment Oral Cavity Cancer: Literature Review and Current Management. 

  • https://www.researchgate.net/publication/303366031_Understand_Cancer_Research_and_Treatment_Oral_Cavity_Cancer_Literature_Review_and_Current_Management

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Doctor #Surgeon #ComplexSurgicalOncologist

#HeadandNeckSurgeon

#CancerSurgeon

#BramanComprehensiveCancerCenter #BCCC

#MountSinaiMedicalCenter #MSMC

#Miami #Mexico

• In general, small and superficial tumors of the oral cavity:
  • Are equally amenable to being cured by:
    • Surgical resection or radiotherapy
• Therefore use of a single modality:
  • Is preferred as the definitive treatment in:
    • Early stage (T1 and T2) tumors of the oral cavity
• When the end point of treatment:
  • That is, cure of cancer:
    • Is comparable:
      • Other factors must play a role in the selection of initial treatment
      • These factors include:
        • Complications
        • Cost
        • Convenience
        • Compliance
        • Long-term sequelae of treatment
• Considering these factors:
  • Surgery:
    • Is the preferred treatment for T1 and T2 tumors of the oral cavity

The goals of treatment of cancer of the oral cavity are:

• Cure of the cancer

• Preservation or restoration of:

  • Speech, mastication, swallowing, and external appearance

• Minimization of the sequelae of treatment such as:

  • Dental decay, osteonecrosis of the mandible, and trismus

• Awareness of the risk of subsequent primary tumors and their management

Jatin P. Shah, Snehal G. Patel & Bhuvanesh Singh. “Jatin Shah’s Head and Neck Surgery and Oncology.” Apple Books. https://itunes.apple.com/us/book/jatin-shahs-head-and-neck-surgery-and-oncology/id535088692?mt=11

 Rodrigo Arrangoiz MS, MD, FACS a head and neck surgeon and is a member of the Braman Comprehensive Cancer at Mount Sinai Medical Center in Miami, Florida.

He is first author on some publications on oral cavity cancer:

• Oral Tongue Cancer: Literature Review and Current Management

  • https://www.oatext.com/pdf/CRR-2-153.pdf

• Understand Cancer: Research and Treatment Oral Cavity Cancer: Literature Review and Current Management.

  • https://www.researchgate.net/publication/303366031_Understand_Cancer_Research_and_Treatment_Oral_Cavity_Cancer_Literature_Review_and_Current_Management

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

• The goals of treatment of cancer of the oral cavity are:
  • Cure of the cancer
  • Preservation or restoration of:
    • Speech
    • Mastication
    • Swallowing
    • External appearance
  • Minimization of the sequelae of treatment such as:
    • Dental decay
    • Osteonecrosis of the mandible
    • Trismus
  • Selecting options with the awareness of the risk of subsequent primary tumors and their management
• Factors that influence the choice of initial treatment for oral cavity cancers are related to:
  • The characteristics of the primary tumor (tumor factors)
  • The patient (patient factors)
  • The treatment team (physician factors)

• The intercostobrachial nerve:
  • This nerve is a cutaneous branch of the intercostal nerves:
    • Most commonly the second intercostal nerve:
      • Which gives off a lateral cutaneous nerve:
        • Which continues as the intercostobrachial nerve
    • The intercostal nerves arise from the anterior rami of the thoracic spinal nerves
  • The intercostobrachial nerve pierces the serratus anterior:
    • Crosses the axilla to the medial side of the upper arm
  • The intercostobrachial nerve is commonly in the surgical field during axillary lymph node dissections:
    • It may be severed during surgery, or subject to traction or postsurgical inflammation:
      • Thus leading to intercostobrachial neuralgia
  • The larger intercostal nerves:
    • Can be preserved with meticulous dissection
• Neuropathic symptoms:
  • May be limited to numbness or tingling:
    • But may also include a burning sensation
• Techniques such as a regional nerve block have been described to alleviate symptoms in severe cases:
  • In a study of 200 patients who underwent axillary dissection:
    • 76% had symptoms of intercostobrachial neuralgia postoperatively
    • Of these patients, 82% reported improvement or resolution of these symptoms within 1 year:
      • Reflecting the richness of the sensory nerve supply to the axilla and upper arm
• The thoracodorsal nerve:
  • Is a branch of the posterior cord of the brachial plexus:
    • Supplies motor function to the latissimus dorsi
  • If injured:
    • Patients experience weakness with arm abduction, lateral flexion, and difficulty with activities such as climbing, swimming, and using the arms to pull the body up
• The medial cord of the brachial plexus:
  • Gives rise to the medial pectoral nerve:
    • Which innervates both the pectoralis minor muscle and the pectoralis major muscle
  • The medial pectoral nerve typically pierces the pectoralis minor muscle:
    • But may wrap around the lateral aspect of the pectoralis minor before traveling on to innervate the distal pectoralis major muscle
• The lateral cord of the brachial plexus:
  • Gives rise to the lateral pectoral nerve:
    • Which innervates the pectoralis major muscle
  • This nerve travels along the medial border of the pectoralis minor muscle, and then along the undersurface of the pectoralis major muscle along with the pectoral branch of the thoracoacromial artery to supply the proximal pectoralis major muscle
• The medial pectoral nerve bundle:
  • Is often encountered during axillary dissection as it is located lateral to the lateral pectoral nerve
• If either of these nerves is injured:
  • Pectoralis muscle atrophy can occur:
    • Which can present as a late complication of surgery:
      • With weakness of shoulder adduction, interior rotation, and flexion
• The long thoracic nerve:
  • Typically arises from anterior rami of the cervical spinal nerve roots C5 to C7:
    • It courses along the chest wall and supplies the serratus anterior muscle
  • Injury to this nerve causes a winged scapula
• References
  • Sclafani LM, Baron RH. Sentinel lymph node biopsy and axillary dissection: added morbidity of the arm, shoulder and chest wall after mastectomy and reconstruction. Cancer J. 2008;14(4):216-222.
  • Wisotzky EM, Saini V, Kao C. Ultrasound-guided intercostobrachial nerve block for intercostobrachial neuralgia in breast cancer patients: a case series. Prev Med Rep, 2016;8(3):273-277.
  • Roses DF, Brooks AD, Harris MN, Shapiro RL, Mitnick J. Complications of level I and II axillary dissection in the treatment of carcinoma of the breast. Ann Sur. 1999;230(2):194-201.
  • Porzionato A, Macchi V, Stecco C, Loukas M, Tubbs RS, De Caro R. Surgical anatomy of the pectoral nerves and the pectoral musculature. Clin Anat. 2012;25(5):559-575.