Nonmelanoma skin cancer of the head and neck: reconstruction

Hypoxia in Skin Cancer: Molecular Basis and Clinical Implications

Skin cancer is one of the most prevalent cancers in the Caucasian population. In the United States, it is estimated that at least one in five people will develop skin cancer in their lifetime, leading to significant morbidity and a healthcare burden. Skin cancer mainly arises from cells in the epidermal layer of the skin, where oxygen is scarce. There are three main types of skin cancer: malignant melanoma, basal cell carcinoma, and squamous cell carcinoma. Accumulating evidence has revealed a critical role for hypoxia in the development and progression of these dermatologic malignancies. In this review, we discuss the role of hypoxia in treating and reconstructing skin cancers. We will summarize the molecular basis of hypoxia signaling pathways in relation to the major genetic variations of skin cancer.

Risk Stratification of Local Flaps and Skin Grafting in Skin Cancer-Related Facial Reconstruction: A Retrospective Single-Center Study of 607 Patients

Background: Non-melanoma skin cancer (NMSC) takes up a substantial fraction of dermatological and plastic surgical outpatient visits and surgeries. NMSC develops as an accumulated exposure to UV light with the face most frequently diagnosed. Method: This retrospective study investigated the risk of complications in relation to full-thickness skin grafts (FTSG) or local flaps in 607 patients who underwent facial surgery and reconstruction at a high-volume center for facial cancer surgery at a tertiary university hospital. Results: Between 01.12.2017 and 30.11.2020, 304 patients received reconstructive flap surgery and 303 received FTSG following skin cancer removal in the face. Flap reconstruction was predominantly performed in the nasal region (78%, n = 237), whereas FTSG reconstruction was performed in the nasal (41,6%, n = 126), frontal (19.8%, n = 60), and temporal areas (19.8%, n = 60), respectively. Patients undergoing FTSGs had a significantly higher risk of hematoma (p = 0.003), partial necroses (p < 0.001), and total necroses (p < 0.001) compared to flap reconstruction. Age and sex increased the risk of major complications (hematoma, partial or total necrosis, wound dehiscence, or infection) for FTSG, revealing that men exhibited 3.72 times increased risk of major complications compared to women reconstructed with FTSG. A tumor size above 15 mm increased the risk of hematoma and necrosis significantly. In summary, local flaps for facial reconstruction after skin cancer provide lower complication rate compared with FTSGs, especially in elderly and/or male patients. The indication for FTSG should be considered critically if the patient’s tumor size and location allow for both procedures.

Reconstructive Techniques in Melanoma for the Surgical Oncologist

Wounds resulting from wide local excision of melanoma vary in size and complexity, and require individualized solutions to achieve satisfactory closure. Goals of reconstruction include restoration of form, function, and aesthetics while minimizing donor site morbidity without compromising the effectiveness and safety of oncologic melanoma treatment. Optimal reconstruction relies on an in-depth understanding of the defect, locoregional anatomy and vasculature, available donor tissues, and basic wound healing and surgical principles. This article provides a broad overview of preoperative patient, timing, and wound considerations; various surgical techniques for complex reconstruction throughout the body; and postoperative care and complication management.

Postauricular Masses

OBJECTIVE

The postauricular region (PR) is an anatomic area that has been neglected until now, due to the fact that the significant cosmetic changes and features of this region are often overlooked. There are limited and inconsistent data about postauricular masses in the literature and the definition of the PR and its borders remain unclear. The aim of the present study was to define the PR and evaluate benign and malignant masses that may arise in the PR.

METHODS

Fifty-two patients were enrolled in the study. The patients were evaluated retrospectively in terms of demographic data, including age, gender, operative method, lesion side and size, diagnostic tools, and histopathologic diagnosis of the masses.

RESULTS

The masses were categorized into 4 groups according to the etiology; neoplastic (n: 15, 28.8%), inflammatory (n: 13, 25%), congenital (n: 22, 42.3%) and traumatic (n: 2, 3.8%). Of the neoplastic masses, 6 (11.5%) were nonmelanoma skin cancer, comprising 4 (7.6%) basal cell carcinomas and 2 (3.8%) squamous cell carcinomas. A total of 9 (17.3%) neoplastic masses were benign, comprising 3 (5.7%) lipomas, 3 (5.7%) temporal bone osteomas, 2 (3.8%) nevi, and 1 (1.9%) plexiform neurofibroma. Of the 13 (25%) inflammatory masses, 12 (23%) were lymph nodes and 1 (1.9%) was pilonidal sinus. There were 22 (42.3%) congenital masses comprising 15 (28.8%) epidermal cysts, 4 (7.6%) dermoid cysts, and 3 (5.7%) hemangiomas. The 2 (3.8%) patients with traumatic lesion were both keloid patients.

CONCLUSION

The PR does not attract attention from the cosmetic point of view but many benign and malignant masses can be found in this region. Any masses detected in this area should be treated to prevent further growth.

A Modification of the Webster-Bernard Lip Reconstruction

We report a modification of the Bernard-Webster lip reconstruction technique which uses the Burrows triangles as V-Y advancement flaps rather than excising them. A 44-year-old white, nonsmoking man presented with a 2-cm cutaneous squamous cell carcinoma of the right lower lip. Oncological resection required excision of 40% of the lower lip to the modiolus. A modified Bernard-Webster flap was used to reconstruct the full length of the lip with minimal donor morbidity.

Nonmelanoma Facial Skin Cancer: A Review of Diagnostic Strategies, Surgical Treatment, and Reconstructive Techniques

Nonmelanoma skin cancer is the most common form of cancer in the United States, and the face is a common area for skin cancer development due to its frequent exposure to the sun. This article focuses on the surgical management of facial nonmelanoma skin cancers, including diagnostic considerations, biopsy techniques, and staging. In addition, we discuss surgical treatment options, including indications, techniques, outcomes, and facial reconstruction following tumor excision.

Facial Skin Cancer Reconstruction

Nonmelanoma skin cancers are the most common skin cancers in the United States and the most common malignancies afflicting the head and neck region. Reconstruction of resulting defects has significant aesthetic and functional implications, and plastic surgeons are frequently consulted for reconstruction. Reconstruction can be accomplished via a multitude of approaches spanning the reconstructive ladder, and the approach should be individualized based upon both patient-related and defect-related factors. Here the authors propose a simplified approach to facial reconstruction broken down by aesthetic region.

The importance of margins in head and neck cancer

An estimated 200,000 deaths each year worldwide are due to cancer of the head and neck, mostly mucosal squamous cell carcinoma and nonmelanoma skin cancer. The status of surgical margins is important for prognosis and need for adjuvant therapy. We will discuss how margin status impacts outcomes and therapy, and the conundrum of determining margin status.

Surface-optimized free flaps for complex facial defects after skin cancer

INTRODUCTION

Advanced non-melanocytic skin cancer (NMSC) in the facial region causes extensive tissue loss, possibly coverable by local flaps. Remote free flaps are the reconstructive method of choice, despite disadvantages such as color and texture mismatch, and bulkiness with regard to facial skin.

MATERIAL AND METHODS

Post-ablative facial NMSC defects in four patients were reconstructed using remote free flaps, including radial forearm, scapular, parascapular, and anterolateral thigh flaps. Four months later, a split-thickness skin graft (STSG) was acquired from the retroauricular region to generate a non-cultured autologous epidermal cell (NCAEC) suspension. The flap surfaces were de-epithelialized, and the NCAEC suspension was sprayed onto the flap surface to improve the mismatch between facial and flap color. Debulking was also carried out. The aesthetic outcome was examined by photography and clinical examination 3, 6, 9, and 12 months after the first operation.

RESULTS

All flaps survived the 11- to 21-month follow-up. The secondary operation was accompanied by a delay in re-epithelialization in one case. No STSG donor-site problems occurred. Follow-up photographs showed significant improvements in the color and texture of the flaps.

CONCLUSIONS

Facial reconstruction with a free flap results in a mismatch of color and texture. Secondary correction of the flap surface by de-epithelialization and NCAEC application significantly improves the aesthetic outcome.

Functional lower lip reconstruction with the modified Bernard-Webster flap

BACKGROUND

Lower lip defects after squamous cell carcinoma (SCC) excisions have been repaired by several surgical techniques. However, the functional reconstruction of full-thickness defects of the lower lip remains a therapeutic challenge. We therefore evaluated functional results of the modified Bernard-Webster flap for the reconstruction of full-thickness lower lip defects after SCC excisions.

METHODS

A prospective study was performed on all patients with lower lip full-thickness defects after SCC excisions greater than 1/3 of the lip, reconstructed with the modified Bernard-Webster flap in 2011-2013. Functional (sphincter, motor, and sensory functions) postoperative results were evaluated according to criteria previously adopted.

RESULTS

Twelve lower lip defects were reconstructed without complications, except for two (16.7%) wound dehiscence successfully managed. Ten (83.3%) patients presented transient and permanent functional abnormalities in the recent and late postoperative assessments. Ten (83.3%) patients classified the late functional results as satisfactory.

CONCLUSIONS

The modified Bernard-Webster flap proved to be an excellent alternative to repair full-thickness lower lip defects with more than 1/3 of the lower lip length, as it allowed the use of similar neighboring tissues, could be performed in one stage, and was functionally effective.

Reconstructive surgery in advanced perioral non-melanoma skin cancer. Results in elderly patients

BACKGROUND

Nonmelanoma skin cancer (NMSC) of the perioral region is not uncommon. Basal cell carcinoma is predominant in the upper lip area and squamous cell carcinoma in the lower lip area. While smaller lesions can be treated by excision followed by primary closure larger defects after tumor surgery can be challenging.

OBJECTIVES

Analysis of outcome after complete surgical excision with micrographical control of excision margins (delayed Mohs surgery) of large NMSC's of the perioral region (lips and chin).

PATIENTS AND METHODS

This is a retrospective, single-center analysis of patients with defects after delayed Mohs surgery of ≥ 3 cm of the perioral region. The study included a total of 25 patients (4 women and 21 men) with a mean age of 83.7 years. Twenty patients were diagnosed with squamous cell carcinoma and five had basal cell carcinoma. The lower lip was affected in 19 patients, the upper lip in 4 patients and the chin in 2 patients. Tumor stage was either T1N0M0 or T2N0M0. The most common procedure for lower lip defect closure was staircase or modified staircase technique. Cheek advancement flaps were used for upper lip defect closure. Inferiorly based nasolabial rotational flap, cheek rotational flap and modified Webster flap were also employed. In one patient Webster flap and unilateral staircase technique were combined.

RESULTS

In all patients the tumor was removed completely with preservation of function and aesthetics. No local recurrence was observed after a median follow-up of 4.9 years.

CONCLUSION

Perioral reconstruction after removal of large NMSC is a complex issue. The age group of over 70 years, frequently with comorbidities, requires a robust surgical technique with short operation times and tailored approaches for defect closure.