Cancer Surgery
Surgical excision follows these principles:
Excision of the tumour with a margin of normal tissue—ideally at least 2cm margin of clinically normal tissue. Intrabony lesions may require a greater anatomical margin due to their tendency to spread along cancellous spaces
A marginal resection preserving the lower border of the mandible, or the superior part of the maxilla may be appropriate for very small lesions
Larger lesions require partial mandibulectomy or maxillectory, with involved soft tissues and lymphatics
Neck dissection – Radical
Removes internal jugular vein, lymphatics, accessory nerve, cervical sensory nerves, sternomastoid, omohyoid, and often digastric muscles
- Functional
Preserves more vital structures
Retain as much normal anatomy and function as possible
* The mutilation of surgery must always be balanced against benefits of complete and radical excision which may effect a cure.
Reconstruction (to produce acceptable function and cosmetics)
Free non-vascularised bone grafts from rib, iliac crest, calvarium – where defects < 5cm, or free vascularized bone transfer for larger defects (fibula graft)
Bone grafts may later permit osseo-integrated implants to be used
In the maxilla an obturator can be used to close an oro-antral fistula, or closure may be achieved surgically
Soft tissue reconstruction with a flap, in small defects using local tissues such as tongue, buccal fat pad, mucosal flaps or skin grafts
In larger defects using either:
Regional flaps—nasolabial, forehead, neck skin, temporalis and masseter muscle flaps
Distant myocutaneous flaps, may be pedicled (pectoralis major, latissimus dorsi, trapezius). These are bulky, but valuable and can be divided later
Free tissue transfer flaps established with microvascular anastomoses and commonly used for oral reconstruction including radial forearm flaps based on the radial vessels, composite fibular free flaps, composite deep circumflex iliac flaps and rectus abdominis flaps based on the inferior epigastric vessels.
Advantages of Surgery
- Complete tumour and lymph node excision with full histological examination
- Removal of involved bone
- Use for radio-resistant tumours
Disadvantages
- Mutilating for very large tumours
- Peri-operative mortality and morbidity
- Aesthetic and functional defects
Post-operative care
Management of the following may require SHO’s to deal with a very unwell patient
- Airway—often with a tracheostomy
- Fluid and blood replacement
- Nutrition—often utilizing PEG feeding and the input of a dietician
- Pain control.