Surgery for oral cancer

Most people with oral cancer will have surgery. The type of surgery you have depends mainly on the size, stage and location of the tumour. When planning surgery, your healthcare team will also consider other factors, such as your age and overall health.

Surgery may be done for different reasons. You may have surgery to:

• completely remove the tumour
• remove lymph nodes if the cancer has spread to them or to prevent the cancer from spreading to them
• reduce pain or ease symptoms (called palliative surgery)

Surgery for oral cancer can affect your appearance and your ability to chew, swallow and speak. Many specialists will work together to plan treatment that will give you the best quality of life. These specialists may include surgeons (head and neck surgeons, reconstructive surgeons and other specialists), radiation oncologists, medical oncologists, dentists, dietitians and speech pathologists.

Some surgeries for oral cancer can be difficult and hard to recover from. It is important to be as healthy as possible before you have surgery. You may have blood tests, such as a complete blood count (CBC) or blood chemistry, blood clotting and liver function tests. You may also have heart and lung function tests to make sure you are healthy enough to have surgery. You will also have a nutritional assessment to check your weight and food intake.

It is important for you to have a full dental exam and receive dental care (if needed) as part of your treatment plan. If you smoke, your healthcare team will encourage you to stop. Smoking can increase the risk of your cancer coming back (recurring) and it can also slow down healing and increase the risk of side effects after surgery.

Surgical resection removes the whole tumour along with a margin of healthy tissue surrounding it. If your tumour is small and easy for the surgeon to reach they will do the surgery through your mouth. If the tumour is larger, the surgeon may need to remove the tumour through a cut in your neck or a cut in your jawbone (called a mandibulotomy). Different types of surgery are used to remove the primary tumour depending on the location of the tumour. You may also have other treatments before or after surgery.

Wide local excision is used to treat small tumours. The tumour is removed with a margin of normal tissue around the tumour. The remaining skin is stitched together or left to heal on its own. If the tumour is removed with positive margins, re-resection is often considered.

Mohs surgery (also called Mohs micrographic surgery) is a surgical method that may be used to treat small cancers on the lip. It is used to remove the tumour and surrounding tissue layer-by-layer until the tissue is completely clear of cancer cells. Mohs is not typically used for sites of oral cancer other than the lip.

Find out more about Mohs surgery.

Glossectomy is surgery to remove part or all of the tongue.

Partial glossectomy is used to treat smaller tumours on the tongue. A small part of the tongue is removed and the wound is closed with stitches or left to heal on its own. If a larger resection is done, a skin graft or a more complex reconstruction may be needed to close the wound. Speech and swallowing problems are not likely after partial glossectomy.

Subtotal glossectomy is used to treat larger tumours on the tongue. A large part of the tongue is removed during this surgery. Reconstruction is done to repair the wound so that you can swallow and speak as well as possible.

Total glossectomy removes the whole tongue. This type of surgery is only used if you have an advanced tumour. This surgery makes eating and speaking difficult. The voice box (larynx) may be removed (called a laryngectomy) at the same time as a total glossectomy if the cancer has spread to the voice box. During a laryngectomy, the surgeon attaches the end of the windpipe to an opening (a stoma) in the neck. You will have a permanent stoma (tracheostomy) and you will not be able to speak normally but can learn other ways of speaking and communicating.

Maxillectomy is surgery to remove part or all of the upper jawbone (maxilla) along with any tumour in the roof of the mouth (the palate). Either a partial or full maxillectomy may be done to remove the tumour. A maxillary prosthesis( called an obturator) may be needed to repair the hole in the roof of the mouth after surgery. In most cases, reconstructive surgery can be done.

Transoral resection may be offered instead of a mandibulectomy, which is usually needed to reach and remove tumours at the back of the mouth or in the throat. Transoral resection is done through the mouth. It is minimally invasive, which means that large cuts aren't needed to remove the tumour. As a result, it causes fewer side effects and less extensive reconstructive surgery is needed than with a mandibulectomy. Transoral resection still completely removes the tumour, so further treatment with radiation therapy or chemoradiation may not be needed.

You may have one of the following types of transoral resection to treat oral cancer:

• Transoral robotic surgery (TORS) uses an endoscope to see the tumour and a computer-based system to guide the surgical tools to remove the tumour.
• Transoral laser microsurgery (TLM) uses an endoscope to see the tumour. The endoscope is connected to a laser that is used to remove the tumour.

Oral cancer can spread to the lymph nodes in the neck. Neck dissection is surgery to remove lymph nodes from the neck. It is usually done when cancer has spread to the lymph nodes in the neck. It may be done at the same time as surgery to remove the tumour. Neck dissection may also be done to prevent the cancer from spreading and reduce the risk that the cancer will recur. Neck dissection is also commonly done to find out whether the cancer has spread to lymph nodes or not.

A neck dissection is usually done:

• when imaging tests suggest there is cancer in the lymph nodes
• when a biopsy shows there is cancer in the lymph nodes
• when a mouth tumour has grown more than 4 mm into an oral structure, to get rid of any possible remaining cancer cells and prevent the risk of cancer recurring in the lymph nodes
• to help plan further treatment or reconstructive surgery

You may have lymph nodes removed on one side of the neck (called ipsilateral neck dissection) or both sides of the neck (called bilateral neck dissection). A neck dissection is often done at the same time as surgery to remove the main tumour. It is sometimes done after surgery, depending on the pathology results.

There are different types of neck dissection. The type of neck dissection done depends on which lymph nodes in the neck the doctors think have cancer in them and whether muscles, nerves or veins need to be removed.

Selective neck dissection removes only a few lymph node regions.

Modified radical neck dissection removes most of the lymph nodes on one side of your neck between the jawbone and the collarbone as well as some muscle and nerve tissues.

Radical neck dissection removes all of the lymph nodes on one side of your neck as well as muscle, nerves and veins.

In some cases, a sentinel lymph node biopsy (SLNB) may be offered as part of the treatment plan for oral cancer to check to see if cancer has spread to the lymph nodes in the neck.

Find out more about neck dissection.

Reconstruction may be needed to repair structures in the mouth and jaw or to restore speech and swallowing after extensive surgery. Reconstruction techniques are constantly improving and different treatment centres can have different approaches to reconstruction. Reconstruction is usually planned at the same time as treatment.

The reconstructive team may include a head and neck surgeon, a head and neck prosthodontist (specialist in restoration and replacement of structures of the head and neck with prosthetics), a head and neck reconstructive surgeon (specialist in reconstruction and plastic surgery of the face) and a speech pathologist.

It is important for the healthcare team involved in reconstruction to assess and talk to you about what your expectations are before any surgery or other treatments are done. The best reconstruction technique for you can be decided by predicting which soft tissues and bones will have to be removed during surgery and which tissues can be used to replace and restore structures and function. Decisions like whether you prefer reconstruction using prosthetics or your own tissue need to be made early in treatment planning. Your healthcare team will create a reconstruction plan just for you, depending on the location of the tumour, your general health and ability to recover from a long surgery and your personal preference.

Reconstruction is often done at the same time as surgery to remove the tumour but it can also be done in a separate surgery. It can be done using skin from another part of the body (called a skin graft), using tissue (skin, muscle, bone or a combination of these) from another part of the body (called flaps) and using prosthetics.

A skin graft replaces an area of skin with skin taken from somewhere else on the body. A skin graft can be used to repair small surgical wounds. It can also be used to cover the area where the surgeon removes tissue for a flap. A special instrument called a dermatome removes layers of skin in sheets. The skin is then transferred to the surgical wound.

There are 2 different types of skin graft used for reconstruction of the mouth.

A split-thickness skin graft includes the top 2 layers of skin from the donor site: the outer layer of skin (the epidermis) and the layer underneath the epidermis (the dermis). Skin is usually taken from the thigh, buttock or upper arm. Skin will grow back in these areas.

A full-thickness skin graft uses the entire thickness of skin: the epidermis, dermis and the fatty layer below the dermis (called the subcutaneous layer). Skin is usually taken from the neck, behind the ears or the inner side of the upper arm. The edges of the skin at the donor site are stitched together to close the wound.

A regional flap( also called a local flap) is a piece of tissue, with or without skin attached, that contains its own blood supply and is used to repair surgical wounds. One end of the tissue is cut away from the body, while the other end remains attached to maintain the blood supply. The flap is stretched or moved to the wound site from an area close by and stitched in place.

A free flap is a piece of tissue that has been completely removed from the donor site and is moved to the site needing repair. This requires very careful surgery to connect the tiny blood vessels of the flap to the vessels of the surgical wound. This type of surgery is known as microvascular surgery. Free flaps are commonly taken from the arms, legs, back or abdomen.

Artificial (prosthetic) facial parts or dental implants can also be used in reconstruction and can help with swallowing and speech. Dental implants or dentures can be used to replace missing teeth. The upper jawbone (maxilla) and the front of the roof of the mouth (the hard palate) can be replaced using a prosthesis. Prostheses can also be used in the mouth to reshape certain structures to improve speech and swallowing. There is often follow-up for adjusting or modifying a prosthesis if necessary.

Surgery may be used to place a feeding tube if oral cancer or its treatment affects your ability to swallow. There are different types of feeding tubes that may be used.

Find out more about tube feeding.

Tracheostomy is done to make an opening (a stoma) in the trachea through the neck so air can reach the lungs. It is sometimes needed when a tumour or swelling presses on or blocks the trachea and makes it difficult to breathe. It may also be done before certain surgeries to protect the airway. It is usually temporary.

You and your caregiver will be told what to expect after surgery. When you wake up, you may have several different tubes. You may have a tube in your neck for breathing (from a tracheostomy). You may have tubes for draining fluid and you may have a feeding tube.

After surgery to the mouth, you will not be able to eat for a few days. A dietitian will give you support and advice about nutrition and any changes that you may have to make to your diet after you leave the hospital. You may also work with a speech therapist if surgery has affected your speech.

Side effects can happen with any type of treatment for oral cancer, but everyone’s experience is different. Some people have many side effects. Other people have only a few side effects.

If you develop side effects, they can happen any time during, immediately after or a few days or weeks after surgery. Sometimes late side effects develop months or years after surgery. Most side effects will go away on their own or can be treated, but some may last a long time or become permanent.

Side effects of surgery will depend mainly on the type and site of surgery and your overall health.

Surgery for oral cancer may cause these side effects:

• pain
• bleeding
• fatigue
• infection
• wound separation
• flap loss
• swelling at the surgery site
• lymphedema
• difficulty swallowing
• difficulty speaking
• chewing problems
• drooling
• difficulty opening the jaw (called trismus)
• weight loss
• nerve damage
• changes in function and appearance of lips
• oral fistulae
• scarring

Tell your healthcare team if you have these side effects or others you think might be from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Find out more about surgery and side effects of surgery. To make the decisions that are right for you, ask your healthcare team questions about surgery.