Visor approach approach to the mandible

The optimal cosmetic result for oromandibular surgery that requires access to the neck is obtained with a combination of an intraoral approach with an extraoral approach via a visor flap. This allows all external incisions to be placed in natural skin creases to improve cosmetic outcome.

This approach allows access to virtually any area of the oral cavity or oropharynx but, does require the release and pull through of advanced oromandibular tumors into the neck.

The neck incision is carried out in a mid-neck crease from mastoid tip to mastoid tip.

The patient is placed supine with a small shoulder roll at the level of the scapula in order to extend the neck.

The patient is prepared in the normal fashion and injections are carried out in the proposed incision lines using local anaesthetic for hemostatic control (eg. epinephrine)

In order to ensure adequate ventilation of the patient both intraoperatively and postoperatively a tracheotomy is performed prior to any surgical manipulation in the oral cavity.

A 3 cm horizontal incision is made just inferior to the cricoid cartilage and dissection is carried down to the strap muscles. The paired muscles are divided in the midline and retracted laterally. The thyroid isthmus is exposed and either retracted superiorly or divided and suture ligated.

An inferiorly based flap (Björk flap) of the second or third tracheal ring is created and sutured to the overlaying skin. The previously placed endotracheal tube is removed and a reinforced endotracheal tube is placed into the tracheotomy site and secured and further ventilation is carried out through this tube.

The neck incision is carried out in a mid-neck crease from mastoid tip to mastoid tip.

It is carried through skin and subcutaneous tissues and platysma muscle and flaps raised superiorly and inferiorly in a subplatysmal plane to expose the entire neck.

The marginal branch of the facial nerve is identified bilaterally, released inferiorly and retracted superior to the mandibular border in order to avoid injury during the resection.

Cervical lymphadenectomies are then carried out as appropriate.

The margins of the mandibulectomy are defined and the mental nerve is divided if part of the planned resection.

The tumor is visualized and 1.5 cm soft tissue margins are marked (eg. with electro cautery) around all visible or palpable tumor in the oral cavity.

The intraoral incisions are connected to the extraoral exposure by making incisions in the gingival buccal sulcus. These connecting incisions are extended laterally, as far as the mandibular angle, to allow for superior rotation of the visor flap.

Care should be taken to avoid undue tension of or injury to the mental nerve on the contralateral side during elevation of the flap. The flap is secured in a superior position.

When the bony reconstruction is completed, the oral mucosa is closed directly to the skin of the flap with interrupted absorbable suture in a vertical mattress fashion (eg. 3-0 Vicryl). A water tight closure is essential to avoid an orocutaneous fistulae and subsequent infection in the surgical site. Care must be taken during closure to avoid injury to the vascular pedicle which may be traversing the defect.

Closed suction drains (eg. Jackson-Pratt drains) are placed in the neck and brought out through stab incisions in the skin. If a vascularized flap has been used for reconstruction, the drains must be placed as so as to not overlay the vascular pedicle of the flap.

The neck is closed in layers. The platysma muscle and deep dermis are closed with resorbable interrupted sutures in buried fashion. The skin is closed with a running resorbable suture (eg. 5-0 fast absorbing gut suture) or non-resorbable suture (eg. 5-0 nylon).