Dermato-onco-surgical outcomes for moderately differentiated squamous cell carcinoma over lower lip treated with karapandzic flap under regional anesthesia

Dear Editor,

Despite the complexity of large malignant lower lip defects, they can be closed surgically with free flaps such as Karapandzic, Bernard, Zisser, Gillies, Abbe, or Estlander flaps, for restoring normal anatomy and oral function.^1-4 We present a case of moderately differentiated squamous cell carcinoma (SCC) on the lower lip treated with a Karapandzic flap (KF).

A 54-year-old male presented with verrucous asymptomatic growth on the left side of the lower lip for 8 months. He had a habit of chewing betel nuts for the past 26 years. Lesion was well-defined, circular (2.8 cm × 2.4 cm) with surface varicosities extending posteriorly from the left lower lip tubercle up to the mucosal surface of the left anterior sulcus. No induration was noted below the lesion nor palpable submental, submandibular, or cervical lymphadenopathy. A provisional diagnosis of malignant neoplasm was made, confirmed as moderately differentiated SCC based on incisional biopsy and histopathology findings [Figure 1].

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Figure 1:

Squamous cell carcinoma involving the lateral lower lip.

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Magnetic resonance imaging and contrasted computed tomography showed lesion infiltration into orbicularis oculi muscle without bone involvement. Fluorodeoxyglucose positron emission tomography showed no local/distant metastasis or lymphadenopathy. Surgical planning included a KF under regional anesthesia.

Area was prepared with povidone-iodine solution. Following flap design, detailed surgical marking for left-sided full-thickness lower lip excision with 1 cm safe margin was done [Figure 2]. Local anesthesia (2% lignocaine) without adrenaline was sequentially administered bilaterally into the external infra-orbital and mental nerves, then intra-oral, infra-orbital, and mental nerves. This was followed by peri-oral subcutaneous infiltration using Klein’s tumescent solution along surgical marking bilaterally below the naso-labial folds, through the mental crease, and finally transcutaneously beneath the lesion over the lower lip. Using a 15-number blade and 3-number Bard Parker handle, linear wedge-shaped incisions vertically up to mid-subcutaneous fat along cutaneous and mucosal surfaces 1 cm surrounding the tumor were gently outlined [Figure 3]. To accelerate the speed of surgery, blade was replaced with needle tip radio-frequency to dissect out primary defect and excise it radically [Figures 4 and 5]. This was followed by gently raising KF by reusing the scalpel. Semi-circular full-thickness vertical incision starting at the base of excised defect was taken along the mental crease, going contralaterally up to the commissure to reach right-sided naso-labial fold, keeping nerves and blood vessels intact [Figure 6]. This step allowed mobilization of orbicularis oculi muscle longitudinally along the line of incision so that its future supply is maintained from the separated adjacent musculature. The scalpel was then lifted and tilted to begin ascent laterally at the level of the commissure along naso-labial fold, going vertically in the level of subcutaneous plane only. A blunt dissection was carried out gently to preserve labial arteries and buccal nerve branches using an artery forceps along the subcutaneous plane of naso-labial fold to facilitate gliding of two excised lip margins toward each other [Figure 7]. Incised flap was lifted and rotated medially to close the defect [Figure 8]. Stay suture was taken in the center after careful approximation of the vermillion border of lip from both margins. Defect was closed in three layers, approximating muscle and mucosa using Vicryl 5.0 and skin using Prolene 5.0, respectively [Figure 9]. Suture line over the external cutaneous surface was occluded with topical mupirocin and secured with sterile gauze and micropore dressing. Excised tissue sent for histopathology revealed neoplasm composed of anastomosing strands of moderately differentiated squamous cells exhibiting nuclear hyperchromatosis, pleomorphism, and mitoses with dense lymphoplasmacytic infiltrate at the tumor stromal interface, confirming a moderately differentiated SCC.

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Figure 2:

Pre-operative surgical marking.

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Figure 3:

Intra-operative incision of primary defect with 15 no. BP blade. BP: Bard-Parker.

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Figure 4:

Intra-operative excision with needle point radiofrequency.

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Figure 5:

Intra-operative excision of primary defect.

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Figure 6:

Intra-operative incision of flap.

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Figure 7:

Intra-operative blunt dissection of raised flap through subcutaneous plane.

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Figure 8:

Intra-operative elevation of flap.

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Figure 9:

(a and b) Intra-operative suturing.

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Alternate suture removal was done on day 8 and remaining on day 12. Follow-up occurred every 3 months for 1 year, then annually for 3 years [Figure 10]. Patients had visible complications of rounding and distortion of commissures and reduction in lower lip circumference that led to microstomia [Figure 11]. Suture line healed in linear atrophic scar with minimal post-inflammatory hyperpigmentation; no recurrence or local/distant metastasis reported. Lower lip function remained intact without physiological compromise, indicating satisfactory oncological and functional outcomes.

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Figure 10:

(a and b) Post-operative at 3 months.

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Figure 11:

Post-operative at 3 years with microstomia.

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The histopathology on hematoxylin and eosin stain revealed neoplasm composed of anastomosing strands of moderately differentiated squamous cells exhibiting nuclear hyperchromasia, pleomorphism, and mitoses. A dense lymphoplasmacytic infiltrate was present at the tumor-stromal interface along with epidermal surface candida colonization. All the cut margins and base were uninvolved by the tumor [Figure 12]. Tumor-free margin in one section revealed 8 mm and 6 mm, respectively, and in another 7 mm and 8 mm, respectively.

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Figure 12:

(a and b) Histopathology stain used hematoxylin and eosin magnification ×10.

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KF being a neurovascular fan flap not only preserves the motor and sensory nerves but also the blood supply to flap. Flaps are commonly designed contralaterally or bilaterally to defect to increase degree of mobilization through these intact vital structures to join the vermilion borders of lip simultaneously.^1,2 It is a single-stage procedure for reconstructing the lower lip following excision of large defects involving part or whole of the lower lip.¹ The rich vascularity maintained through intact superior and inferior labial arteries facilitates complete nourishment of large volumes of rotated lip tissue. Due to the lack of new tissue recruitment, this procedure may yield inferior aesthetic outcomes. It results in post-operative microstomia and commissural distortion, correctable with commissuroplasty. Minimal circumoral scarring can be treated with fractional lasers. Minimally visible circumoral scarring along suture lines can be corrected with fractional lasers.^1,3,4

The novelty of this case lies in the incorporation of nerve blocks with tumescent anesthesia to facilitate a KF procedure, ensuring sustained intraoperative efficacy. Postoperatively, our case demonstrates satisfactory dermato-oncologic outcomes following excision of large lower lip defects, with minimal microstomia and scarring. The nerve blocks followed by local anesthesia around and below the lesion helped in sustained anesthetic effect for the execution of tumor radical excision present over a high neuro-vascular bundle area. However, this can have few limitations intraoperatively such as edema, distortion of margins of tumor, and vermilion border of lips, pooling of blood in oral mucosa and involuntary movement of lips.