Reconstruction of Mohs Defects Located in the Head and Neck

Reconstruction of nasal and upper lip defect using bilateral inferiorly based malar transposition flaps: A case report

INTRODUCTION AND IMPORTANCE

Surgical flaps are accepted as the best option for nasal reconstructions depending on various factors, including defect etiology, size, location, and depth.

CASE PRESENTATION

A 71-year-old man presented with a squamous cell carcinoma of the columella extended to the nasal tip and upper lip. He underwent Mohs resection followed by staged reconstruction with bilateral inferiorly-based malar transposition flaps. Then, the patient was scheduled for radiation therapy for fourweeks. The patient had been free of recurrence after a two-year follow-up.

CLINICAL DISCUSSION

In this case, the inclusion of the upper lip and columella defect restricted our choices. However, the bilateral malar transposition flap effectively covered both nasal and upper lip defects, providing an excellent tissue match without the need for a skin graft. This method is particularly suited for extensive multiple nasal subunits and upper lip defects.

CONCLUSION

A malar transposition flap may be an adequate alternative for columella and upper lip reconstruction after skin cancer resection.

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.

Long-Term Patient-Reported Outcomes following Oncological Facial Reconstructive Surgery using the FACE-Q Skin Cancer Module

Background

Long-term patient-reported outcomes (PROs) of oncological facial reconstructive surgery are unknown.

Objective

The present study aimed to assess long-term PROs and to identify possible correlations between patient and treatment characteristics and long-term PROs.

Methods & Materials

Between 2006 and 2011, 202 patients underwent facial reconstruction after Mohs micrographic surgery for non-melanoma skin cancer at our institution. After 10 years of follow-up, 96 out of the remaining 122 patients completed the FACE-Q Skin Cancer Module.

Results

Patients who were surgically treated for squamous cell carcinoma reported poorer scores on the satisfaction with facial appearance (p=0.038), appraisal of scars (p=0.039) and appearance-related psychosocial distress scales (p=0.036) compared to patients with basal cell carcinoma and lentigo maligna. Finally, female patients reported significantly higher scores on the Cancer Worry Scale than male patients (p=0.047).

Conclusion

Long-term patient satisfaction with respect to their facial appearance and scars after reconstructive surgery for skin cancer was comparable to short-term patient satisfaction, whereas Cancer Worry Scale and psychosocial distress appeared to be slightly higher. Our results can be used to better inform patients on the long-term effects of facial reconstructive surgery on patient satisfaction and quality of life, which are important to improve patient counselling, patient expectation management and shared decision-making.

Impact of the COVID-19 Pandemic on the Diagnosis and Management of Non-Melanoma Skin Cancer in the Head and Neck Region: A Retrospective Cohort Study

The present study investigates the impact of the COVID-19 pandemic on the management of Non-Melanoma Skin Cancer (NMSC) in the head and neck region. Conducted at the University Hospital "Le Scotte" in Siena, Italy, the research includes 111 patients treated from 2018 to 2021. The study aims to understand how pandemic-related healthcare changes affected NMSC treatment, focusing on differences in diagnosis and management before and during the pandemic. Methods involved retrospective analysis of patient demographics, clinical characteristics, lesion details, and treatment modalities, using Jamovi software (version 1.6) for statistical analysis. Results revealed the scalp as the most common NMSC site, with Squamous Cell Carcinoma (SCC) being the predominant histotype. A significant rise in Basal Cell Carcinoma (BCC) cases and a reduction in surgery duration were noted during the pandemic. The shift to local anesthesia was more pronounced, reflecting the necessity to adapt to healthcare limitations. Despite the disruptions caused by the pandemic, there was no significant drop in NMSC cases, which is attributed to the noticeable nature of head and neck lesions. In conclusion, this study highlights that the COVID-19 pandemic significantly influenced surgical practices in NMSC management, emphasizing the need for effective healthcare strategies that balance quality patient care with public health safety measures.

Nasal reconstructive techniques following Mohs surgery or excisions: a systematic review

Numerous reconstructive techniques for nasal defects following skin cancer removal have been described; however, the literature lacks a comprehensive systematic review. Our objective was to systematically review nasal reconstruction methods after tumor removal, correlate the use of specific techniques to the nasal subunits involved, assess the quality of the available evidence, and set the stage for future research on this topic. Eight databases were searched for studies published in English from January 2004 to December 2018 containing repair data for nasal defects following Mohs or excision for four or more subjects. Recorded data included author specialties, study design, subject number, demographics, defect characteristics, procedure type, reconstructive methods, outcome measures, and complications. One-hundred and eleven studies were included. Study types included case series (73%), observational cohort studies (25%), and clinical trials (2%). Most authors were dermatologic surgeons (61%). Resection was most commonly performed via Mohs (82%). Flaps (42%), linear closures (28%) and grafts (25%) were most utilized for reconstruction. In Zones I and II, transposition flaps were the most common followed by advancement flaps. In Zone III, full thickness skin grafts were the most common repair. Most studies were case series or small cohort studies, representing low level evidence. Flaps are the most common method described in the literature for nasal reconstruction. The overall quality of the evidence available on this topic is low.

Mohs Defect Repair with Dehydrated Human Amnion/Chorion Membrane

Importance: Reconstructing cosmetically sensitive defects in an aging population undergoing multiple Mohs micrographic surgeries (MMS) may be addressed with alternatives to surgery.

Objective: Patients undergoing MMS with defect reconstruction in visually prominent areas receiving placental allograft were compared with traditional autologous tissue-based procedures—flaps and full-thickness skin grafts (FTSG).

Design, Setting, and Participants: This retrospective case–control study evaluated patients who underwent MMS for removal of a basal or squamous cell carcinoma with same-day repair.

Main Outcomes and Measures: The primary endpoint was the incidence and comparison of postoperative morbidity. Risk for developing medical or cosmetic sequelae was determined through multivariate logistic regression.

Results: The study population consisted of 143 propensity score-matched pairs (n = 286) with moderate- to high-risk defects on the face, head, and neck. Compared with autologous tissue, placental allograft cases were associated with significantly lower risk for infection (p = 0.004), poor scar cosmesis (p < 0.0001), scar revision (p < 0.0001), or reoperation (p = 0.0007).

Conclusions and Relevance: Postoperative complication rates for placental reconstructions did not exceed those demonstrated by autologous tissue counterparts, indicating this is a safe alternative to flap and FTSG in cosmetically sensitive repairs.

Morbidity Associated With Structural Graft Use in Paramedian Forehead Flap

INTRODUCTION

Paramedian forehead flap for nasal reconstruction may involve the use of a structural graft. The authors hypothesized that the use of structural grafts with paramedian forehead flap is associated with an increased risk of 30-day complications.

METHODS

This is a retrospective study of the American College of Surgeon (ACS) National Surgical Quality Improvement Program (NSQIP). We identified all patients undergoing paramedian forehead flap reconstruction from 2007 through 2018 using Current Procedural Terminology code 15731. Patients who had structural graft harvested at the time of paramedian forehead flap were identified using Current Procedural Terminology codes. Groups were defined based on the use of structural grafts. Propensity score matching was performed using preoperative and intraoperative characteristics to produce matched cohorts. The authors further stratified individual graft types to identify differential risks associated with each. Logistic regression was then used to determine whether the use of structural grafts was associated with increased risk for 30-day complications.

RESULTS

The authors identified 1198 patients with paramedian forehead flap reconstruction, of whom 325 (27.1%) required structural grafts. Propensity score matching 1:1 yielded 247 patients in each of the matched cohorts. Overall 30-day complications (4.5% versus 5.3%), wound related complications (3.2% versus 4.1%), systemic complications (1.2% versus 2%), unplanned reoperation (6.5% versus 3.2%), and unplanned readmission (6.6% versus 10.2%) were similar between the 2 groups (P > 0.05). Subgroup analysis of different graft types showed that costochondral graft was associated with increased wound related complications (0.9% versus 8.3%, P = 0.03). The odds of having wound related complications with the use of costochondral graft was OR = 5.3, CI = 1.5-18.8, P = 0.02.

CONCLUSIONS

Although the use of structural grafts does not increase risk of overall 30-day complications, there is an increased risk of wound related complications associated with the use of costochondral and rib grafts.

Mohs micrographic surgery: a review of indications, technique, outcomes, and considerations

Mohs micrographic surgery is a specialized form of skin cancer surgery that has the highest cure rates for several cutaneous malignancies. Certain skin cancers can have small extensions or “roots” that may be missed if an excised tumor is serially cross-sectioned in a “bread-loaf” fashion, commonly performed on excision specimens. The method of Mohs micrographic surgery is unique in that the dermatologist (Mohs surgeon) acts as both surgeon and pathologist, from the preoperative considerations until the reconstruction. Since Dr. Mohs’s initial work in the 1930s, the practice of Mohs micrographic surgery has become increasingly widespread among the dermatologic surgery community worldwide and is considered the treatment of choice for many common and uncommon cutaneous neoplasms. Mohs micrographic surgery spares the maximal amount of normal tissue and is a safe procedure with very few complications, most of them managed by Mohs surgeons in their offices. Mohs micrographic surgery is the standard of care for high risks basal cell carcinomas and cutaneous squamous cell carcinoma and is commonly and increasingly used for melanoma and other rare tumors with superior cure rates. This review better familiarizes the dermatologists with the technique, explains the difference between Mohs micrographic surgery and wide local excision, and discusses its main indications.