Reconstruction after wide excision of primary cutaneous melanomas: part I—the head and neck

Social Perception of Reconstruction following Orbital Exenteration

Background:

Orbital exenteration, the removal of the entire globe, eyelids, and orbital content, is indicated in extensive neoplastic disease involving the orbital region. Although a functional reconstruction of orbital exenteration defects is mandatory, aesthetic concerns need to be considered. Facial disfigurement following reconstructive surgery often leads to great discomfort and social retirement, which can limit social interaction. The aim of this study was to explore how the society perceives the aspect of patients who underwent orbital exenteration and subsequent reconstruction, comparing two different types of reconstruction: standard anterolateral thigh (ALT) or “sandwich” fascial ALT (SALT) free flap.

Methods:

An online survey was created based on four questions regarding the perception of reconstruction (discomfort at looking at that patient, perception of unhealthiness, hypothesis of social life impairment, etc); five possible answers were provided, ranging from “completely” to “not at all.” The survey was administered to the general population and to medical students.

Results:

In total, 255 people participated to the survey (130 medical students and 125 people of the general population); a total of 245 surveys were considered eligible (10 were incomplete and then discharged). Statistical significance was found (P < 0.001) regarding the better overall appearance of the SALT group over the ALT one.

Conclusions:

After analysis, the surgical outcome after SALT reconstruction has been found to be less disruptive in both groups, due to a reduced scar burden and a more pleasant orbital pocket. Our results encourage more research in the field of postexenteration reconstruction to achieve more aesthetic and social acceptability.

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.

Predictive indicators for revisional surgery in nasal reconstruction after Mohs surgery

Background

Reconstruction of nasal lesions is complex due to the topography, mobile free margins and borders of anatomical subunits. Reconstructive challenges can lead to multiple revisional surgeries to achieve the final aesthetic result. This study aimed to evaluate risk factors and predictors of revisional surgery in patients undergoing reconstruction after Mohs micrographic surgery for nasal tumours.

Methods

This was a prospective cohort study from April 2, 2008 to February 26, 2019. The study population included all consecutive patients who underwent Mohs micrographic surgery for nasal skin cancer. Resection and reconstruction of nasal skin cancer was performed by the Mohs team.

Results

A total of 988 cases met our study inclusion criteria with 64 (6.5%) cases requiring unplanned surgical revision. Revision rates were highest in the ala (9.0%, p < 0.05) and complex anatomical subunits (16.7%, p < 0.0001). In contrast, revision rates for dorsum lesions were lowest (1.8%, p < 0.001). In terms of reconstructive modalities, local flaps resulted in significantly higher rates of revision when compared to grafts (relative risk, 2.37; 95% CI, 1.15–5.0; p < 0.01). In terms of histological diagnosis, squamous cell carcinoma had significantly higher revision rates when compared to basal cell carcinoma (p < 0.05).

Conclusions

To our knowledge, this is the first study to report the risk factors and predictors of revision surgery in patients undergoing MMS for nasal tumours. This study highlights that the reconstructive modality utilised affects the functional and cosmetic outcome of MMS. We note that ala complex subunit lesions, squamous cell carcinoma and flap reconstruction were associated with an increased risk of revision after Mohs reconstruction of nasal lesions.

Level of evidence: Level III, risk/prognostic; therapeutic study.

Trial registration number

(Ref: PLA-19-20_A03) 04/02/2020.

Prognostic factors in head and neck melanoma according to facial aesthetic units

BACKGROUND

Head and neck melanoma is a clinical challenge. Indeed, cutaneous head and neck melanoma shows a worse prognosis in comparison to melanomas of other body sites. Although the emphasis on facial cosmetic preservation plays a pivotal role in comparison to other body areas, specific Facial Aesthetic Units (FAU) could also play a key role in the prognostic evaluation of the malignancy.

METHODS

The aim of the current study was to evaluate the general outcome and clinicopathological features of head and neck melanoma and to detect prognostic differences according to each FAU. The Kaplan-Meier product was used to calculate survival curves, while Cox proportional-hazard regression was performed to evaluate the predictive value of each FAU.

RESULTS

A total of 221 head and neck melanoma patients was included in our analysis. In the nasal FAU, we found a high rate of local recurrence, which affected significantly disease-free survival. The worse prognosis was observed in melanoma of the scalp, which showed a greater tendency to skip metastases in internal organs. Moreover, we found that scalp showed a low incidence of non-melanoma skin cancers, if compared to other FAU, highlighting that the scalp local milieu might play a more prominent role in melanoma biology than chronic UV exposition.

CONCLUSIONS

Although FAUs have an aesthetic function, they could also play a role in the evaluation and follow-up of melanoma.

Sandwich Fascial Anterolateral Thigh Flap in Head and Neck Reconstruction: Evolution or Revolution?

Supplemental Digital Content is available in the text.

Introduction:

The anterolateral thigh perforator flap (ALT) represents the workhorse for most reconstructive efforts in the head and neck regions. The main advantages of this flap are its versatility, the length of the pedicle, and the low morbidity of the donor site. The major drawback is the bulkiness of this flap with the frequent need for secondary revisions. To overcome this, we have developed a novel way to harvest and inset the ALT, called the sandwich fascial ALT flap (SALT).

Methods:

All patients undergoing head and neck reconstruction using the SALT flap from January 2013 to March 2016 were included in this retrospective analysis. The SALT flap was harvested as a composite flap including the superficial fascia, the subscarpal fat, and the deep fascia. At the recipient site, the flap was inset with the deep fascia facing out. A split thickness skin graft (± dermal substitute) was used to cover the deep fascia and the pedicle.

Results:

Eleven patients were included: 8 cases of orbital exenteration, 1 case of forehead reconstruction, and 2 cases of palatal reconstruction after radical maxillectomy. Flap survival was 100%. One patient required an early take back for venous thrombosis. The reconstruction was effective in all cases, allowing a prosthetic rehabilitation when required. Donor-site morbidity was minimal.

Conclusions:

The reconstruction of head and neck defects with a bulky fasciocutaneous ALT flap might not be the best option in every case. The SALT flap could represent a valid alternative for selected cases, with encouraging functional and cosmetic outcomes.

Oncologic reconstruction: General principles and techniques

Halsted's principle of radical mastectomy influenced cancer treatment for decades. Randomized controlled trials resulted in a paradigm shift to less radical surgery and the use of adjuvant therapies. Oncologic reconstruction performed by plastic surgeons has evolved, ranging from skin grafts and local flaps for smaller defects to pedicled flaps and free flaps for larger and more complex defects. Immediate reconstruction facilitates resection is oncologically safe and contributes to meaningful improvements in quality of life. J. Surg. Oncol. 2016;113:852-864. © 2016 Wiley Periodicals, Inc.

Reconstruction of Large Cheek Defect With/Without Sideburn Using Malar-Posterior Auricular-Cervico Flap

The cheek region is the most common site for malignant tumor occurrence and the treatment of malignant skin tumor requires extensive local excision. Many previous reports have covered methods of reconstruction using local flaps for skin defects in the cheek region.In this article, we describe our experience with a surgical reconstruction using a new flap method for 8 patients with missing tissue in the cheek region. This flap is based on the concept of separately designing the flap with the 3 areas comprising the malar, posterior auricular, and cervical regions. We named the flap containing these 3 regions the malar-posterior auricular-cervico flap. Esthetically satisfactory outcomes were achieved in all cases.In conclusion, we recommend our malar-posterior auricular-cervico flap to reconstruct the tissue defects of approximately 20 to 40 cm after tumor excision in the cheek region. If preauricular skin is included in the design of this flap, the sideburn can be reconstructed using a part of the nape region with hair.

Lymphatic and blood vasculature in primary cutaneous melanomas of the scalp and neck

BACKGROUND

Scalp/neck melanomas have a poor prognosis, possibly because of a rich vascular supply that prompts tumor cells' dissemination.

METHODS

We compared the accuracy of immunohistochemical (IHC) staining with morphology for the identification of lymphovascular invasion in 156 scalp/neck melanomas. We then analyzed the association of vessel invasion and density with pathological features and survival.

RESULTS

IHC-detected lymphatic vessel invasion (LVI) and blood vessel invasion (BVI) were identified in 34.6% and 13.5% of cases, respectively. IHC increased the LVI/BVI detection compared to morphology (40.4% vs 16.6%; p < .001). The degree of peritumoral and intratumoral blood vessel density (BVD) was greater than lymphatic vessel density (LVD). Ulceration was the only factor independently associated with intratumoral (p = .029) and peritumoral (p = .047) BVD. Tumor thickness was the only independent predictor of survival (p = .002).

CONCLUSION

IHC allows accurate assessment of lymphovascular invasion in scalp/neck melanomas. In these tumors, we observed a high incidence of BVI, which deserves further investigations.

An analysis of cheek reconstruction after tumor excision in patients with melanoma

BACKGROUND

The most common site for melanoma occurrence is the cheek region, and the treatment of melanoma requires extensive local excision. This study evaluated factors that influence the selection of reconstructive procedures after excision of a cheek melanoma.

METHODS

A total of 26 cases (12 with skin grafts, 7 with local flaps, and 7 with free flaps) were included in the study. Factors in the selection of reconstructive procedures were evaluated by examining the size of the skin defects, patient age, and prognosis.

RESULTS

Free flaps were frequently used in cases with large areas of skin defect and with thicker melanomas. Skin grafts were used for a wide variety of tumor thicknesses and for older patients with thick melanomas (due to the general condition of the patients). The dividing line of the range of skin defects between local and free flaps was approximately 40 cm. Reconstruction procedures had no impact on prognosis.

CONCLUSIONS

In deciding on a reconstruction procedure after the excision of a cheek melanoma, 3 factors are important: the range of the skin defect, the severity of the melanoma, and the age of the patient.

The importance of adequate primary tumor excision margins and sentinel node biopsy in achieving optimal locoregional control for patients with thick primary melanomas

OBJECTIVE

This study sought to investigate the impact of histopathologically measured excision margins and SNB on local and locoregional disease control in patients with primary cutaneous melanomas more than 4 mm thick.

BACKGROUND

Most current guidelines recommend at least a 2-cm surgical margin (which corresponds to a 16-mm histopathologic margin). These guidelines are based on limited evidence, mostly obtained in patients who did not have an SNB.

METHODS

Histopathologic tumor excision margins for clinically lymph node-negative patients with melanomas more than 4 mm thick, treated at Melanoma Institute Australia (1992-2009), were determined. Clinicopathologic predictors of local and locoregional disease-free survival were investigated.

RESULTS

There were 632 patients eligible for the study; of these, 397 (62.8%) had an SNB. The median histopathologic excision margin was 15 mm (interquartile range, 11.0-19.5 mm). After a median follow-up of 37 months, local and locoregional recurrences were observed in 48 (7.6%) and 159 (25.2%) patients, respectively. Excision margin as a continuous variable was a significant predictor of local [hazard ratio (HR), 0.91; P < 0.001) and locoregional (HR, 0.97; P = 0.042) tumor control on multivariate analyses. Patients with histopathologic margins 16 mm or less had worse local disease-free survival (HR, 2.41; P = 0.01). Patients who did not have an SNB were at higher risk of locoregional recurrence (HR, 1.67; P = 0.003).

CONCLUSIONS

Histopathologically determined primary tumor excision margins more than 16 mm, corresponding to 2-cm surgical margins, were associated with better local control in patients with melanomas more than 4 mm thick. Patients achieved the best local and locoregional control when SNB was coupled with a more than 16-mm histologic excision margin.

[Giant abdomino-pubic melanoma. A case report]

Cutaneous melanoma patients are usually young adults. The evolution into a nodular form darkens the prognosis because it increases the risk of metastasis occurrence. The only curative treatment is wide surgical excision when extension check is negative. We report a case of abdomino-pubic melanoma original by its amazing size, its spreading, both superficial and nodular, without metastasis, and its late occurrence to a senior patient. Curative management was performed with a plastic surgery technique: the abdominal plasty. The melanoma was removed with free margins and the patient was free of disease at six month. This report illustrates the interest of plastic surgery techniques in oncology. It also confirms that plastic surgeon forms an integral part of a multidisciplinary team managing patients with cutaneous melanoma.