Nonmelanoma skin cancer of the head and neck II: surgical treatment and reconstruction

Practice Patterns and Outcomes of Skin Cancer Reconstruction of the Head, Neck, and Face by Surgical Specialty: An NSQIP Analysis

INTRODUCTION

Reconstructive procedures of the head, neck, and face after skin cancer resection are typically performed by surgeons trained in either ENT facial plastic surgery or plastic and reconstructive surgery. We analyzed a large national database to compare patient populations, practice, and outcomes of skin cancer reconstruction of the head, neck, and face performed by these 2 surgical specialties.

METHODS

Cases were selected from the American College of Surgeons National Surgical Quality Improvement Program. Variables that differed significantly on univariate analysis were included in a nominal logistic regression, with having at least 1 wound-specific complication, medical complication, or unplanned reoperation within 30 days as the dependent variables.

RESULTS

There were a total of 2850 cases, of which 61.36% were performed by ENT. Surgical specialty was not found to be a predictor of wound complications, medical complications, or unplanned reoperations. On multivariate analysis, operative times greater than 6 hours and anatomical location (specifically, skin cancer of the nose) predicted adverse outcomes. Significant differences were observed between the patient populations of the 2 specialties in terms of demographics, comorbidities, and the anatomical location of the cancer defect.

CONCLUSION

Reconstruction of the head, neck, and face after skin cancer removal represents an important and common element in the scope of practice of both ENT facial plastic surgeons and plastic surgeons. No evidence was found to suggest that surgical specialty is associated with adverse postoperative outcomes. However, ENT facial plastic surgeons and plastic surgeons seem to manage unique patient populations and use different reconstructive techniques, reflecting their distinct training and areas of expertise. A multidisciplinary approach where the complementary skills of both specialties can be leveraged may optimize patient outcomes.

Resection of Skin Cancer Resulting in Free Vascularized Tissue Reconstruction: Always a Therapeutic Failure?

The globally increasing incidence of cutaneous malignancies leads, in parallel, to increasing numbers of locally advanced skin cancer resulting in reconstructive surgery. Reasons for locally advanced skin cancer may be a patient's neglect or aggressive tumor growth, such as desmoplastic growth or perineural invasion. This study investigates characteristics of cutaneous malignancies requiring microsurgical reconstruction with the aim of identifying possible pitfalls and improving diagnostic and therapeutic processes. A retrospective data analysis from 2015 to 2020 was conducted. Seventeen patients (n = 17) were included. The mean age at reconstructive surgery was 68.5 (±13) years. The majority of patients (14/17, 82%) presented with recurrent skin cancer. The most common histological entity was squamous cell carcinoma (10/17, 59%). All neoplasms showed at least one of the following histopathological characteristics: desmoplastic growth (12/17, 71%), perineural invasion (6/17, 35%), or tumor thickness of at least 6 mm (9/17, 53%). The mean number of surgical resections until cancer-free resection margins (R0) were achieved was 2.4 (±0.7). The local recurrence rate and the rate of distant metastases were 36%. Identified high-risk neoplastic characteristics, such as desmoplastic growth, perineural invasion, and a tumor depth of at least 6 mm, require a more extensive surgical treatment without concerns about defect size.

Factors affecting outcomes of second intent healing of nasal defects after Mohs micrographic surgery

Reconstruction of nasal defects secondary to Mohs micrographic surgery (MMS) presents particular challenges related to the complex topography, skin quality, tissue laxity, and functional and aesthetic concerns of the region. Factors affecting outcomes resulting from second intent healing (SIH) on the nose have not been well described. The purpose of the study was to identify factors impacting outcomes of SIH for nasal tumors following MMS. Retrospective analysis was performed of all nasal lesions treated with MMS followed by SIH from a single surgical center over a 1.5-year period. Ninety-six cases were included. Chart review was performed, and data were collected including age, gender, nasal site, tumor type, defect size, depth, and number of MMS stages. Pre- and post-operative follow-up photographs were available for all cases. All five authors evaluated the photographs using the modified Manchester scar scale. Analysis was then conducted to identify features associated with good outcomes. Of the 96 tumors, 39 lesions (40.6%) were located on the nasal tip (including supratip), 32 (33.3%) on the ala/alar groove, 17 (17.7%) on the sidewall, and 8 (8.3%) on the dorsum. The average defect size was 0.83 cm² (diameter of 1.06 cm ± 0.4). Defect diameter and defect depth were the factors that significantly impacted scar outcome (p < 0.001) in multivariate analysis. No significant functional deficits were reported. This retrospective study suggests that nasal defects with area less than 0.83 cm² (or 1.06 cm diameter) and depth of defect not extending beyond the superficial fat healed well by SIH regardless of location on the nose.

Improving reconstructive surgery design using Gaussian process surrogates to capture material behavior uncertainty

To produce functional, aesthetically natural results, reconstructive surgeries must be planned to minimize stress as excessive loads near wounds have been shown to produce pathological scarring and other complications (Gurtner et al., 2011). Presently, stress cannot easily be measured in the operating room. Consequently, surgeons rely on intuition and experience (Paul et al., 2016; Buchanan et al., 2016). Predictive computational tools are ideal candidates for surgery planning. Finite element (FE) simulations have shown promise in predicting stress fields on large skin patches and in complex cases, helping to identify potential regions of complication. Unfortunately, these simulations are computationally expensive and deterministic (Lee et al., 2018a). However, running a few, well selected FE simulations allows us to create Gaussian process (GP) surrogate models of local cutaneous flaps that are computationally efficient and able to predict stress and strain for arbitrary material parameters. Here, we create GP surrogates for the advancement, rotation, and transposition flaps. We then use the predictive capability of these surrogates to perform a global sensitivity analysis, ultimately showing that fiber direction has the most significant impact on strain field variations. We then perform an optimization to determine the optimal fiber direction for each flap for three different objectives driven by clinical guidelines (Leedy et al., 2005; Rohrer and Bhatia, 2005). While material properties are not controlled by the surgeon and are actually a source of uncertainty, the surgeon can in fact control the orientation of the flap with respect to the skin's relaxed tension lines, which are associated with the underlying fiber orientation (Borges, 1984). Therefore, fiber direction is the only material parameter that can be optimized clinically. The optimization task relies on the efficiency of the GP surrogates to calculate the expected cost of different strategies when the uncertainty of other material parameters is included. We propose optimal flap orientations for the three cost functions and that can help in reducing stress resulting from the surgery and ultimately reduce complications associated with excessive mechanical loading near wounds.

Reconstruction of Cutaneous Cancer Defects of the Head and Neck

The goals of cutaneous malignancy reconstruction are to restore the best functional and aesthetic outcome. Reconstruction should aim to restore all defects layers. While local flaps are the mainstay of head and neck Mohs reconstruction, the range of reconstructive options varies from healing by secondary intention to microvascular free tissue transfer.

Single-Stage Reconstruction of Full-Thickness Nasal Alar Defect Using Bilobed and Turnover Flaps

Skin cancer of the nose remains a common challenge for the reconstructive surgeon with full-thickness defects being particularly problematic. Reconstruction of the internal nasal lining poses the greatest difficulty with local tissue often having unsatisfactory vascularity or surface area. We describe the reconstruction of a full thickness nasal alar defect in a patient after failed full-thickness skin graft using a single stage procedure combining a bilobed flap with a turnover flap. The patient achieved excellent initial and long-term cosmesis and functionality and was very satisfied with the results. We demonstrate that selected full-thickness nasal alar defects may be reconstructed in a single procedure using a carefully placed turnover flap for the internal nasal lining and bilobed flap for outer skin cover.

Surgical Excision with Rotational Flap Reconstruction for Basosquamous Cell Carcinoma in Xeroderma Pigmentosa: A Case Report

Xeroderma pigmentosa (XP) is a rare autosomal recessive disorder which is characterized by a defect in nucleotide excision repair of DNA following exposure to UV radiation. This leads to hypersensitivity to sunlight causing pigmented skin lesions, photophobia and a 1000-fold increase in risk of developing cutaneous malignancies like basal cell carcinomas, squamous cell carcinomas and melanomas of head and neck. We present an interesting case of a 28 year old man with basosquamous cell carcinoma secondary to XP treated successfully with surgical excision and reconstruction with rotational flap technique.

Recurrence of periocular basal cell carcinoma and squamous cell carcinoma after Mohs micrographic surgery: a retrospective cohort study

Background

Despite the widespread use of Mohs micrographic surgery (MMS) for periocular basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) – together called keratinocyte carcinoma (KC) – follow‐up data regarding recurrences are limited.

Objectives

To investigate the recurrence rate for periocular KCs after MMS and to describe our experience with interdisciplinary collaborations.

Methods

Patients with periocular KCs treated with MMS between 2006 and 2016 in a tertiary MMS referral hospital were included in this retrospective cohort study. Descriptive statistics were used to describe the MMS procedure‐related characteristics. Using follow‐up data from the electronic patient records and linkage with the Dutch nationwide network and registry of histopathology and cytopathology on 30 June 2017, the recurrence rate was evaluated and calculated using a cumulative incidence curve.

Results

In total, 683 (93·7%) periocular BCCs and 46 (6·3%) SCCs were treated with MMS. Three‐quarters (n = 549) were primary tumours and the majority were located at the medial canthus or lower eyelid (n = 649, 89·0%). In 505 MMS procedures (69·3%) an oculoplastic surgeon participated, and in 63 patients (8·6%) a plastic surgeon performed the reconstruction. After a median follow‐up of 46 months the recurrence rate was 3·0%, based on 22 recurrences (20 BCCs and two SCCs).

Conclusions

MMS is an excellent treatment option for periocular KCs, with a low recurrence rate. Due to this specific anatomical location an interdisciplinary approach should pre‐eminently be considered.

What's already known about this topic?

Mohs micrographic surgery (MMS) is a widespread treatment for periocular basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) because of the expected high cure rate, while preserving healthy tissue.

Follow‐up data on the risk of recurrence after periocular MMS are limited.

What does this study add?

This retrospective cohort study demonstrates that with a recurrence rate of 3·0% after almost 4 years, MMS has proven to be an excellent surgical treatment option for periocular BCC and SCC.

We advise a low threshold for interdisciplinary collaborations, especially in case of recurrent BCCs, BCCs localized in the medial canthus and aggressive BCCs.

Linked Comment: https://doi.org/10.1111/bjd.17736.

https://www.bjdonline.com/article/

Fourth Dimension in Reconstruction of Defects Following Excision of Basal Cell Carcinoma of Head and Neck!

Background:

Basal cell carcinomas (BCCs) are the most common skin tumors of the face. Excision results in soft tissue defects that require reconstruction with the focus on form, function, and patient satisfaction.

Aim:

To analyze the reconstruction of BCC excision defects of the head and neck region using local flaps and skin grafts with respect to the four dimensions of oncological reconstruction: clearance, form, function, and patient satisfaction.

Materials and Methods:

This is a prospective study conducted on 88 patients who presented with BCC of the head and neck region and who were operated in our hospital from January 2015 to December 2016 with a minimum follow-up period of 6 months up to June 2017. All patients underwent wide local excision and reconstruction using appropriate local flaps or split-thickness skin graft (SSG). Patients were analyzed with respect to age, sex, site, size, reconstruction method, complications, and patient satisfaction using the customized Patient Satisfaction Questionnaire (PSQ), derived from PSQ III.

Results:

A total of 77.3% defects were immediately reconstructed using local flaps and 18.2% underwent SSG. All flaps and grafts survived well with a complication rate of 6.8%. Approximately 72.7% of patients had good satisfaction with the medical care and reconstruction.

Conclusion:

Post-excisional defects of BCC in the head and neck region have to be reconstructed with equal weightage to the four pillars of oncological reconstruction: clearance, form, function, and patient satisfaction. Flap reconstruction is ideal as it brings about reconstruction with patient satisfaction, which is indeed the fourth dimension in any reconstructive surgery.

Variable response of post-Mohs surgery telangiectasias to KTP laser: A case report

A common but under-recognized complication of Mohs micrographic surgery is the development of surgical site telangiectasias after repair. Treatment with pulsed dye laser has shown good results in treating periscar telangiectasias, while treatment with KTP laser has never been studied for this complication. We report the findings in six patients with persistent telangiectasias post-Mohs micrographic surgery and their response to treatment with KTP laser. After one treatment with KTP laser, the severity of telangiectasias, scar erythema, and patient and physician-rated improvement were recorded. Response to KTP laser was variable. However, this case series suggests that KTP laser may have the potential to improve the appearance of periscar telangiectasia after Mohs micrographic surgery.

Strategies to Mitigate Variability in Engineering Human Nasal Cartilage

Skin cancer and its associated treitments can have devastating consequences for survivors; this is particularly true when cancer occurs on the nose. Recent work has applied cell-based tissue engineering (TE) strategies to develop nasal cartilage constructs for reconstruction of the nose. In this study, we have generated human nasal cartilage on a clinically approved collagen scaffold to investigate the donor-to-donor variability of TE cartilage and evaluated strategies to mitigate it. We also evaluated the gene expression of the family of fibroblast growth factor receptors (FGFR1-4) and their association with tissue quality. FGFR1 was significantly positively correlated with GAG/DNA; a measure of chondrogenic capacity. We implemented two strategies: hypoxic culture and co-culture with mesenchymal stromal cells (MSCs) to increase tissue quality. Total glycosaminoglycan (GAG) content varied significantly between donors initially, with >10–fold difference between the best and worst donor tissue. Our co-culture strategy was able to increase TE construct quality from poor quality donor tissue while supressing hypertrophy relative to MSCs alone. However, no differences were observed with the use of hypoxic culture. Tissues generated using co-culture with MSCs became vascularized and calcified in vivo, demonstrating a non-stable cartilage phenotype in co-culture and MSCs cartilage constructs.

Surgical Treatment and Recurrence of Cutaneous Nasal Malignancies: A 26-Year Retrospective Review of 1795 Patients

Frequent localization of facial malignancies in the nasal area and their required complete surgical extirpation pose a significant challenge to the plastic surgeon, who is called to perform a suitable delicate reconstruction of produced nasal skin defects. The present study was aimed to examine the role of tumor characteristics in the prognosis of patients with nasal skin cancer undergoing surgical management.A retrospective review of 1795 patients operated on for nasal cutaneous neoplasms during a 26-year period is presented in our study. Descriptive statistics were appropriately calculated; multivariate Cox regression analysis was performed regarding the possible risk factors for recurrence. Only those with a complete follow-up were included in the study. The mean age of our study population was 66.7 years with a male majority (52.4%). Basal cell carcinoma appeared as the most common histological type (87.7%), followed by squamous cell carcinoma (7.9%); the latter correlated with poor prognosis.The nasal sidewalls were the most frequent lesion location (29.8%), followed by the alae (27.8%), dorsum (21.7%), and tip (19.3%). The columella was very rarely affected (0.5%) but was associated with increased recurrence [hazard ratio, 4.74; 95% confidence interval (CI), 1.12-20.00; P = 0.034]. Most patients were treated with elliptical excision and direct closure (58.7%). Local flaps (31.0%) and skin grafting (9.0%) proved very reliable surgical options, especially for larger, high-risk lesions. Recurrence transpired in 46 patients (2.6%) and 4 skin cancer-related deaths occurred.Surgical modality of choice should be individualized and carefully adjusted to patients' needs. Moreover, more elective techniques, such as Mohs micrographic surgery or cumulative therapeutic approaches, like irradiation, should be examined as a beneficial aid to confront high-risk malignancies.

Simulation-Based Rhomboid Flap Skills Training During Medical Education

OBJECTIVE

To assess if the bench model fidelity interferes in the acquisition of rhomboid flap skills by medical students.

METHODS

Sixty novice medical students were randomly assigned to 5 practice conditions with instructor-directed Limberg rhomboid flap skills training: didactic materials (control group 1), low-fidelity rubberized line (group 2) or ethylene-vinyl acetate (group 3) bench models; high-fidelity chicken leg skin (group 4) or pig foot skin (group 5) bench models. Pretests and posttests were applied, and Global Rating Scale, effect size, and self-perceived confidence were used to evaluate all flap performances.

RESULTS

Medical students from groups 2 to 5 showed better flap performances based on the Global Rating Scale (all P < 0.05) and felt more confident to perform rhomboid flaps (all P < 0.05) compared to their peers from control group 1, regardless of bench model fidelity (all P > 0.05). The magnitude of the effect was considered large (>0.80) in all measurements.

CONCLUSION

There was acquisition of rhomboid flap skills regardless of bench model fidelity.

Reconstruction of small soft tissue nasal defects

Nasal defect repair has been one of the more challenging areas of reconstructive surgery due to the lack of uniform nasal skin thickness and complex contours. Currently, algorithms for medium to large nasal soft tissue defects have been well defined by various authors. Small defects, arbitrarily defined as 1 cm or less, still present significant challenges. In this article, the authors examine the options available to repair small soft tissue nasal defects and the appropriate situations in which each method is best suited.

Comparison of tissue-engineered and artificial dermis grafts after removal of basal cell carcinoma on face--a pilot study

BACKGROUND

Planning reconstruction for facial defects should include the safest and least-invasive methods, with a goal of achieving optimal functional and cosmetic outcomes.

OBJECTIVE

To compare tissue-engineered dermis grafts with artificial dermis grafts after removal of basal cell carcinoma (BCC) on the face.

MATERIALS AND METHODS

A tissue-engineered dermis composed of autologous cultured dermal fibroblasts seeded on a hyaluronic acid sheet was applied to 16 patients. Grafting of hyaluronic acid sheets that did not contain fibroblasts (artificial dermis group) was performed in 13 patients. Healing time, scar condition, and patient satisfaction were compared.

RESULTS

The wounds of the tissue-engineered dermis group reepithelialized after 31.4 ± 5.3 days and those of the artificial dermis group after 34.2 ± 4.9 days. The tissue-engineered dermis graft was superior in scar quality. In particular, statistically significant differences were detected in the height and contracture of scars, although there were no significant differences in terms of scar texture or color match. Patient satisfaction in the tissue-engineered dermis graft group (8.3 ± 1.0) was also statistically superior to that in the artificial dermis group (6.9 ± 1.4).

CONCLUSION

The tissue-engineered dermis graft is superior to the artificial dermis graft for covering defects after removal of BCC on the face.

Island pedicle and bilobed flaps in ala and back nose reconstruction: a prospective comparative analysis

BACKGROUND

Reconstruction of face deformities resulting from skin cancer includes reconstructing the area with similar tissue. This prospective study aimed to compare the functional and aesthetic outcomes between two types of local flaps (the island pedicle flap vs the bilobed flap) used in reconstruction of the ala and back nose.

METHODS

In this study, 120 patients with skin cancer of the nose underwent ala and back reconstruction: 60 patients using the island flap (IF group) and 60 patients using the bilobed flap (BF group). The two groups were homogeneous for sex, age, and anatomic area. Complications, scarring according to the scale of Vancouver, cosmetic appearance, and disorders of sensations were analyzed, and statistical analysis was performed using Chi-square and analysis of variance (ANOVA).

RESULTS

Early complications were more common in the BF group than in the IF group (p < 0.005). The Vancouver Scar Scale scores were significantly better for the IF patients (p < 0,005), who also showed better results in the analysis of cosmetic outcomes (p < 0.005).

CONCLUSION

The study showed that the island flap used for ala and back nose reconstruction provides better functional and cosmetic results than the bilobed flap, from both functional and aesthetic points of view.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article.

Characteristics of basal cell carcinoma of the lip treated using Mohs micrographic surgery

BACKGROUND

There is a lack of U.S-based studies on basal cell carcinoma (BCC) of the upper lip treated using Mohs micrographic surgery (MMS).

OBJECTIVE

To explore characteristics of BCC of the upper lip treated using MMS.

METHODS

We performed a chart review of BCC cases from 2005 to 2011.

RESULTS

Two hundred eighty-one cases were identified. There was a slight female predominance (55%). Men had a larger initial (p < .01) and final (p = .03) defect size. Infiltrative tumors had larger initial (p < .01) and final areas (p < .01). Ten percent of tumors were designated recurrent after previous treatment. Recurrent lesions (p < .001) and older age (p = .03) were associated with larger initial size. Complex reconstruction was required: 44% by local flap or graft and 13% by plastic surgery.

CONCLUSION

There was a 1.2:1 female to male ratio, in contrast to the previously reported female predominance of 3.5:1. This cohort showed a higher recurrence rate than reported in the literature. Men and elderly patients were also found to have significantly larger initial lesion size. Thirteen percent of patients required repair by plastic surgery, reflecting heightened levels of cosmetic concern. These findings suggest that MMS is important in delineating subclinical tumor spread and providing complex repairs.

[Advanced skin tumors (incurables?) of the cephalic extremity: surgical considerations]

Suggest a surgical thinking for a multidisciplinary problem is inevitably difficult. Nevertheless, through targeted clinical examples, we tried to prioritize our clinical and intellectual approach for advanced tumors of the cephalic extremity. In these cases, decisions can only be collegial, and respect for the patient and his choices remain essential. Ultimately, we would argue this problematic, discussing successively the histological type, ethical concern with regard to clinic, operability and reconstruction opportunities.

Reconstruction of nasal skin cancer defects with local flaps

Reconstruction of nasal defects must preserve the integrity of complex facial functions and expressions, as well as facial symmetry and a pleasing aesthetic outcome. The reconstructive modality of choice will depend largely on the location, size, and depth of the surgical defect. Individualized therapy is the best course, and numerous flaps have been designed to provide coverage of a variety of nasal-specific defects. We describe our experience in the aesthetic reconstruction of nasal skin defects following oncological surgery. The use of different local flaps for nasal skin cancer defects is reported in 286 patients. Complications in this series were one partial flap dehiscence that healed by secondary intention, two forehead flaps, and one bilobed flap with minimal rim necrosis that resulted in an irregular scar requiring revision. Aesthetic results were deemed satisfactory by all patients and the operating surgeons. The color and texture matches were aesthetically good, and the nasal contour was distinct in all patients. All scars were inconspicuous and symmetrical. No patient had tenting or a flat nose.

Basal cell carcinoma of the head and neck

Basal cell carcinoma (BCC) is a malignant neoplasm derived from nonkeratinizing cells that originate from the basal layer of the epidermis and is the most frequent type of skin cancer in humans, with cumulative exposure to ultraviolet radiation as an important risk factor. BCC occurs most frequently at sun-exposed sites, with the head and neck being common areas. Tumors can be classified as nodular, superficial, morpheaform, infiltrating, metatypic, and fibroepithelioma of Pinkus. Several treatment options such as surgical excision and nonsurgical procedures are available. The choice of treatment should be determined based on the histological subtype of a lesion, cost, its size and location, patient age, medical condition of the patient, treatment availability, and the patient's wishes. The aim of any therapy selected for BCC treatment involving the head and neck is to ensure complete removal, the preservation of function, and a good cosmetic outcome.

The bilobed flap in skin cancer of the face: our experience on 285 cases

BACKGROUND

This article describes how many of the defects caused by oncological surgery can be closed with an easily estended flap.

PATIENT AND METHOD

The Zitelli bilobed flap was used to treat 285 consecutive patients with basal cell carcinomas (BCCs) or squamous cell carcinomas (SCCs); 167 men (58.60%) and 118 women (41.40%) between 45 and 98 years of age. Histologically, 247 BCCs (86.6%) and 38 SCCs (13.4%) were documented. Regarding the site, 148 (51.9%) involved the nose, 51 (17.9%) the cheeks, 36 (12.6%) the preauricular region, 27 (9.5%) the perilabial region and chin and 23 (8.1%) the periorbital region. To measure long-term satisfaction patients responded to a telephone survey consisting of a single global question.

RESULTS

The size of the defect following tumour removal was between 1 and 4cm. Carcinomas up to 1cm were treated using a one step procedure with a cryostat test of the surgical margins; all others cases were treated using two step procedure after excision and histological in sano resection. Completely acceptable aesthetic and functional deficits were obtained in 275 (96.4%) patients over a 6-72-month follow-up. Ten (3.6%) patients suffered postoperative complications. Two cases of local infection; one case of completely flap necrosis and seven cases of partial revision due to flap necrosis occurred. The level of satisfaction with the surgical long-term result reported by the patients was high.

CONCLUSION

In our experience the bilobed Zitelli flap for covering defects in the area of the face showed very few complications and good aesthetic results.