Mouth cancer can occur on the lips, gums, tongue, inside lining of the cheeks, and the roof and floor of the mouth.Mouth cancer and other head and neck cancers are often treated similarly.

Reconstructive surgery in this area also goes hand-in-hand with cosmetic surgery, whereby surgeons look to achieve the best functional and aesthetic results.  The aim is to enable patients to chew, swallow, speak and perform other core functions to the best of their ability, while also minimising the visual impact of the surgery and the cancer.

Types of oral cancers
Mouth cancer is a general term that applies to cancers that occur on the lips and throughout the mouth. More specific terms for these types of cancer include:

• Cancer that affects in the inside portion of the cheeks (buccal mucosa cancer)

• Floor of mouth cancer

• Gum cancer

• Lip cancer

• Roof of mouth (hard palate) cancer

• Salivary gland cancer

• Tongue cancer

How do Head and Neck Cancers first present?
Head and neck cancers can present in a number of ways but important symptoms are:

• An ulcer or sore area that does not heal within a few weeks

• Difficulty in swallowing, or pain when chewing or swallowing

• White or red patches inside the mouth

• Loose tooth

• Persistent blocked nose, or nose bleeds

• Constant sore throat and earache on one side

• Swelling or lump in the face, mouth or neck

• Pain or numbness in the face or upper jaw

Some of these symptoms are things that we all might experience temporarily.  If these symptoms are persistent and progressive you should consult your doctor about them.  As with many cancers if diagnosed early cure is usually possible.

Mouth cancer occurs when cells on your lips or in your mouth develop changes (mutations) in their DNA. These mutations allow cancer cells to grow and divide when healthy cells would die. The accumulating mouth cancer cells can form a tumor. With time they may spread to other areas of the mouth and on to other areas of the head and neck or other parts of the body.

Most oral cancers are squamous cell carcinomas. It's not clear what causes the mutations in squamous cells that lead to mouth cancer.
 
What are the risk factors?

• Tobacco use of any kind, including cigarettes, cigars, pipes, chewing tobacco and snuff, among others

• Heavy alcohol use

• Excessive sun exposure to your lips

• A sexually transmitted virus called human papillomavirus (HPV)

• Previous cancer or radiation treatments in the head or neck area

What surgery is available, and what techniques are involved?
In view of the wide variety of head and neck tumours, the nature of the operations involved vary widely from simple local anaesthetic procedures for skin cancers to complex resections and reconstructions for the more advanced or inaccessible tumours.  Each operation involves removal of the tumour followed by an appropriate reconstruction to repair the defect.  Some tumours require division of the bones of the facial skeleton and reconstruction of bone defects.

Flaps for reconstruction of Oral Defects

1. Local Flaps

• Cheek Flap

• Tongue Flap

• Nasolabial Flap

• Temporopariental Fascia Flap

2. Regional Flaps

• Pectoralis Major Myocutaneous Flap

• Deltopectoral Flap

• Sternocleidomastoid Flap

3. Distant Flaps

• Free Radial Forearm Flap

• Free ALT Flap

• Free Islanded Fibula Flap

• Free DP Flap

What is a free flap? A free flap is a graft of human tissue which is taken together with its supplying blood vessels and placed in another part of the body where it is reconnected to a blood supply by microsurgery.  The main benefit of flap surgery is that surgeons can tailor the reconstruction very precisely to a patient’s needs.  Depending on the nature of the defect caused by the surgical excision, surgeons can make free flaps either thin and pliable, or bulky and padded.  Skin, oral lining, muscle, cartilage and bone can all be reconstructed. The flap technique also enables surgeons to reduce what is called donor site morbidity – which means reducing the damage caused to the area from where the flap tissue has been taken.
1. ALT Free Flap The anterolateral thigh free flap (ALT) first described by “Song” has emerged as a popular option for reconstruction of head and neck defects. It has the attributes of a “workhouse” flap which includes a skin and subcutaneous tissue paddle from the  anterolateral thigh skin supplied by the descending branch of the lateral circumflex femoral artery. Advantages of this flap are absence of patient repositioning, remote location from the potential defect, and a long vascular pedicle.
2. Radial Artery Forearm Free  Flap The Radial Forearm Free Flap is dependant for its vascular supply on the Radial artery one of the vessels supplying the hand. A square paddle of skin and soft tissue and sometimes bone is taken from the inside surface of the forearm near the wrist along with two blood vessels, (radial artery and cephalic vein). Once the flap of skin is raised it is transferred to the head and neck and sewn into the defect created by the removal of your cancer. The blood vessels supplying and draining the flap are then joined to blood vessels in your neck under a microscope. These blood vessels then keep the flap alive while it heals into its new place.
3. Free Fibula Osteocutaneous Flap The Free Fibula Osteocutaneous Flap uses part of the fibula bone of the lower leg for reconstruction of the  mandible after removal of the mandible. Its obvious advantage is that of a well-vascularized bone that is durable to infection and radiation. The fibula, although not the ideal source for bone volume, is still sufficient for dental rehabilitation with implants. The fibula is nourished by the peroneal vessels, which are large (2±4 mm in diameter) and convenient for micro-anastomosis. It is relatively easily shaped to the desired bone defect. Its skin paddle can replace intra-oral lining, outer skin or both.

What will it look like?
Initially the flap will be a bit swollen and requires close monitoring by the doctors on the ward to check that its blood supply is working well without any problem. Once the critical initial period is over the flap heals into place and settles to its final shape.

Jaw resection and reconstruction
Modern free flap reconstructive techniques mean that even the removal of large parts of the jaw can be effectively replaced with excellent functional and cosmetic results.                     
 
Which Specialists are involved in treatment?
Most patients with head and neck cancer initially present to a GP or dentist.  A referral will be made to the hospital and the patient will be seen by an appropriate superspecialist and, where appropriate, in a Combined Head and Neck clinic. In a combined clinic patients are seen by a multi-disciplinary team working together to make sure that the best possible treatment is given. These specialists include the following:

• Plastic and Reconstructive Surgeon

• ENT Surgeon/Oral and Maxillofacial Surgeon

• Clinical Oncologist

• Speech therapist

• Radiologist

• Pathologist

• Dietician

• Clinical nurse specialist

Combined operations, involving more than one surgical specialty, are often in the patient's best interests and some patients also require combined forms of treatment ncluding radiotherapy and/or chemotherapy.
 
What should I expect in terms of treatment, procedures and outcomes?
A precise diagnosis is established by a good clinical examination along with a FNAC test, or tissue biopsy .  At times biopsy may need to be done under a short general anaesthetic combined with an endoscope examination of the tumour and surrounding areas.  For some tumours scans are particularly helpful in showing the nature and extent of the growth.  Both MRI and CT scans are used.

This process will establish the diagnosis and stage the disease.  Staging is important in establishing the best treatment and to let the patient know the chances of cure.

Once the results of these tests are known patients are seen again by the MDT (see above) who will discuss with you what treatment is required, and what you can expect.

For some head and neck cancers radiotherapy alone is the most appropriate treatment.  For some patients surgery alone is used.  Some patients will benefit from a combination of treatments.  Sometimes there may a choice to be made between two possible lines of treatment, you will be given advice and support in making this decision.

If you are having an operation the type of procedure varies considerably depending on the site of the tumour.

Face and lips
Small skin cancers and lip cancers are often treated under local anaesthetic as day cases.  Larger tumours may need a general anaesthetic and a day or so in hospital.  There will be some swelling and bruising that should settle in a week or so.  Usually there will be some stitches to be removed.

Scarring on the face whilst lumpy and red at first tends to settle down well.  In most cases the operation will result in cure and no further treatment is needed.

For some tumours a period of follow up as an outpatient will be recommended to check for any evidence of recurrence.