Reconstructive Surgical Procedures for Oral Cancer

Introduction

Oral cancer includes mouth and throat cancers and can develop on the tongue, the floor of the mouth, buccal mucosa, lip, palate, and back of the throat. The occurrence of oral cancer is more commonly seen in the male than in the female population. Squamous cell carcinoma is the most common type of oral cancer, followed by mucoepidermoid carcinoma. The most common causes of oral cancer include smoking, chewing tobacco, and alcohol consumption.

What Are the Stages of Oral Cancer?

The basic stages of cancer after the physical examination and from the results of the biopsy are as follows:

• Stage 0: This stage is called carcinoma in situ. Abnormal cells in the lip and oral cavity lining can be seen during a biopsy.

• Stage 1: Early stage. The tumor size is not more than 2 centimeters. Cancer has not reached the lymph nodes.

• Stage 2: The tumor size is more than 2 centimeters but less than 4 centimeters, and cancer has not reached lymph nodes.

• Stage 3: The tumor size is more than 4 centimeters and has spread to the lymph nodes.

• Stage 4: Advanced stage and can be of any size. The tumor may spread to tissues, jaws, the oral cavity, and lymph nodes.

What Are Reconstructive Surgical Procedures?

The soft tissues, bones, and teeth removed during resection surgery are replaced with grafts transferred from different body parts. Reconstructive surgery is done at the same time as removing the tumor.

What Are the Types of Reconstructive Surgical Procedures for Oral Cancer?

There are three main types of oral reconstruction. They are soft tissue reconstruction, bone reconstruction, and dental prostheses.

A. Soft Tissue Reconstruction

1. Skin Graft: Skin from another body part, like the abdomen or leg, is used for minor shallow defects. A thin sheet of skin removed from different sites is not visible, much like the inner thigh.

2. Free Flap Tissue: Tissue taken from other body parts called free flaps or local flaps. When a larger area of soft tissue is removed, it is replaced by healthy tissue that includes skin, muscle, and fat. If the flap tissue is taken from nearby places like the scalp, cheek, neck, or forehead, then the blood vessels are not disconnected. When free flaps are taken from distant parts of the body, microvascular surgery is performed to cut and join together small blood vessels to restore blood flow to the tissue to perform different functions like chewing, swallowing food, and speaking. Examples of free flaps include tissues from the intestine, abdominal muscle, and arm muscle. In addition, selecting appropriate flaps helps restore functions, like forearm skin, and underlying muscle and fat are used to replace the tongue to regain speech and swallowing. Other flaps include pedicle flaps (commonly used), pectoralis major myocutaneous flaps, and platysma myocutaneous flaps.

3. Nerve Graft: Removing a nerve from unnoticeable sites to restore sensation and functions of lip and tongue like speech and swallowing.

B. Bone Reconstruction

• Bone graft transplanted from other body parts is used to reconstruct the diseased or removed part of the mouth.

• The maxillary jaw (upper) and mandibular jaw (lower) are reconstructed after resectioning the tumor from the bone. During tumor removal, the entire tumor and the tissue surrounding the tumor are also removed so that no tumor cells remain. It depends on the stage of the cancerous cells.

• The surgical removal of the mandible is called mandibulectomy. A partial or marginal mandibulectomy removes small portions of the mandible. At the same time, segmental mandibulectomy removes a large portion.

• In mandibular reconstruction, the lower leg bone, the fibula with artery, vein, and soft tissue is used for reconstruction.

• Other bones, like the hip bone and shoulder blade, can also be used for mandibular reconstruction.

• Reconstruction after maxillectomy (surgery that removes hard palate) can be done by prosthesis, skin graft, or piece of muscle from the forearm or thigh. Palatal obturators can be used to close defects in the roof of the mouth. Palatal obturators can be made with full or partial dentures or prostheses.

C. Dental Implants

• After the reconstruction of the upper or lower jaw, dental implants or prostheses are used to regain the function of chewing and facial muscle appearance. Dental implants are titanium screws inserted into the bone to place a crown and abutment.
• Dental implants consist of three parts, the implant body, the abutment, and the crown. The implant body is the screw inserted into the bone, which supports the dentures. The abutment is the part of the implant where the crown is fixed.

What Are the Risks and Side Effects of Reconstructive Surgery?

• There is a high chance of infections after reconstructive surgical procedures. Increased temperature, shivering, unwellness, redness around the wound, and fluid seeping from the wound are common symptoms of an infection.

• There will be persistent numbness which usually disappears after a few months, but for some people, there will be a loss of sensation in that particular region.

• Flap failure usually occurs when blood vessels are blocked with clots, there will be no blood supply, and discoloration will be visible after 48 hours of the surgery.

• Blood clots, infections, and complications from anesthesia are commonly seen.

• Small types of reconstructive surgeries may have only pain.

• In case of significant defects, infection, wound breakdown, swelling, bruising, bleeding, problems with eating, swallowing, speech impairment, and breathing difficulty can be seen. In some cases, it will be fatal.

• It is necessary to have a skilled and well-experienced doctor for reconstructive surgery.

• A facial reconstruction surgery patient may find that the appearance may have changed and may have head and neck disfiguration. It is necessary to discuss it with the doctor about it before the surgery itself.

What Is the Process of Recovery Post-reconstructive Surgery?

• Recovery from reconstructive surgery varies depending on the level of surgical procedure.

• Minor surgeries like skin grafts will take only two to three days.

• In cases of extensive procedures like jaw reconstruction or free flap tissue, it will take a week or more than that.

• Specialized therapists will work with the individual to restore speech, breathing, and swallowing functions. Physical therapy is like walking in the case of a leg bone graft.

• Exercise regularly.

• Follow a healthy diet.

• The quality of life will be different from pre-reconstructive surgery. Patients will find difficulty with interactions and heightened consciousness of their appearance. They will have many emotional ups and downs. Lending a patient ear and support will be required.

• Smoking can aggravate the chance of tumors coming back. Quit smoking.

• Additionally, services from specialties like nutrition, pain management, oncology rehabilitation, behavioral health, and others can be availed for better patient recovery and management.

Conclusion

Oral cancer is one of the most commonly seen cancers nowadays. Swellings, thickening, eroded areas on gums, cheeks, and other parts of the mouth, and white and red patches are the symptoms of oral cancer. Treatment of oral cancer includes surgical removal, radiation therapy, chemotherapy, targeted drug therapy, and immunotherapy. Most people do oral reconstruction after resection of oral cancer. Oral reconstruction is needed for eating, swallowing, and speaking purposes. Facial reconstruction after oral cancer can sometimes result in deformation of the face.