Effect of margins on local control. NED indicates no evidence of disease. Status of the margins was a significant (P<.005) predictor of local control.
This patient presented with a large neglected basal cell carcinoma of the face. It involved the orbit, maxilla, and a large cutaneous component.
A and B, The resection involved a large cutaneous component in addition to parts of the maxilla, orbital rim, and the orbital contents.
A, The reconstruction was performed with a rectus abdominis free flap. This tissue provides a significant amount of bulk that will atrophy predictably. B, The inferior orbital rim was reconstructed with a Medpor implant (Medpor; Porex Surgical, Inc, Newnan, Ga) that was wrapped with the rectus abdominis flap. C, The final results show the orbital rim and soft tissue reconstruction. A split-thickness skin graft was used to line the external component of the rectus muscle.
Follow-up photographs obtained at 3 months (A) and 6 months (B).
Wax MK, Burkey BB, Bascom D, Rosenthal EL. The Role of Free Tissue Transfer in the Reconstruction of Massive Neglected Skin Cancers of the Head and Neck. Arch Facial Plast Surg. 2003;5(6):479-482. doi:10.1001/archfaci.5.6.479
From the Departments of Otolaryngology–Head and Neck Surgery, Oregon Health & Science University, Portland (Drs Wax and Bascom), Vanderbilt University, Nashville, Tenn (Dr Burkey), and University of Alabama, Birmingham (Dr Rosenthal).
Background Most skin cancers involving the head and neck region are easily managed with surgical resection and local flap rotation. Occasional patients present with massive neglected skin cancers or skin cancers that have recurred after multiple treatments. Management of these massive tumors may involve craniofacial resection, maxillectomy, or mandibulectomy to obtain clear margins. Reconstruction requires massive composite soft tissue replacement. We presented our experience with, to our knowledge, the largest series reported to date.
Design A retrospective chart review of 43 patients with massive neglected skin cancer of the head and neck reconstructed by means of free tissue transfer from January 1, 1992, through October 1, 2001.
Setting Academic tertiary referral medical center.
Results Seventeen patients with squamous cell carcinoma and 26 patients with basal cell carcinoma were treated. Primary sites included the cheek (n = 15), ear (n = 8), forehead (n = 5), neck (n = 4), scalp (n = 5), and nose (n = 6). Treatment involved a combination of orbital exenteration (n = 16), maxillectomy (n = 12), mandibulectomy (n = 6), auriculectomy (n = 5), craniofacial resection (n = 10), rhinectomy (n = 6), and lateral temporal bone excision (n = 5). Flaps used for reconstruction included the rectus abdominis (n = 22), latissimus dorsi (n = 11), radial forearm (n = 8), and lateral arm (n = 2). Radiotherapeutic exposure included pretreatment in 21 patients and posttreatment in 15. Twelve patients had undergone no previous surgeries; 15 patients, 1 to 5; and 16 patients, more than 5. Follow-up revealed evidence of local recurrence (n = 12), locoregional recurrence (n = 3), distant metastasis (n = 3), and no evidence of disease (n = 25).
Conclusions Massive skin cancers are generally associated with disfiguring, debilitating surgery and high mortality rates. We demonstrate that free tissue transfer yields acceptable survival with functional and cosmetic outcomes.
THE PRESENCE of a lesion on the human face is quickly and easily detected by the patient or his family. Most lesions that are skin cancers are amenable to simple resection. Reconstruction is accomplished by primary closure, local flaps, or secondary intention after complete excision. Most patients have a benign clinical course with excellent cosmetic and functional outcomes.1 Rare patients will present with facial skin cancers that involve large surface areas and, to variable degrees, the subcutaneous structures, adjacent organ systems, or facial skeleton. In these instances, treatment involves a large tissue resection. The resultant defect can be devastating from a cosmetic and functional perspective.1-3
The large amount of soft tissue and possible bony skeletal resections make reconstruction of these defects problematic. The need to separate the intracranial contents from the oral or sinus cavity, combined with the large volume of tissue, complicates their reconstruction. Furthermore, local tissue flaps are often inadequate because they lack tissue volume.3-5 A history of radiotherapy exposure makes local tissue transfer a tenuous form of reconstruction.6 In the past, prosthetic rehabilitation was the only viable option.6 In the hands of experts, prosthetics are an excellent rehabilitative modality; however, not all patients have access or can afford the time or expense of this form of rehabilitation.
The advent of free tissue transfer has allowed reconstructive surgeons the ability to reconstruct composite tissue defects with similar composite tissue. The variety of free tissues available for transfer ranges from thin fascial to osteocutaneous to large bulky myocutaneous flaps. The reliability and use of secondary soft tissue sculpturing make these flaps very attractive for these defects. With them, many of these large, composite tissue defects secondary to ablation can be successfully reconstructed.2, 7-10
This article reviews the treatment of patients with massive facial skin cancers who presented to and were treated at a tertiary referral center. The clinical course and need for free tissue transfer to accomplish functional and cosmetic reconstruction are delineated. This review demonstrates that disease-free intervals can be quite good if negative margins are obtained at the time of surgery.
We reviewed the medical records of all patients who presented with massive facial cancers requiring free-flap reconstruction. The patients presented to the Departments of Otolaryngology–Head and Neck Surgery at Vanderbilt University, Nashville, Tenn, West Virginia University, Morgantown, or Oregon Health & Science University, Portland. The study encompassed the period from January 1, 1992, through October 1, 2001. Patient hospital medical records were reviewed, and data recorded included patient demographics, age, sex, tumor histological findings, previous treatment, extent of surgery required for removal, and status of the margins. The type of flap used for reconstruction was recorded. Exposure to radiation or adjuvant therapy, whether preoperative or postoperative, was also recorded. We reviewed the various procedures performed to enhance function or form, and disease status at last follow-up.
Forty-three patients (38 men and 5 women) were treated during the time frame of this study. The average age was 63 years (range, 44-82 years). Follow-up averaged 25 months (range, 5-47 months). Primary sites were predominantly on the cheek and ear, as seen in the following tabulation:Article
Thirty-one patients had undergone previous surgical treatment (1-5 treatments for 15 patients and ≥6 for 16). Most patients underwent some form of radiotherapy, including preoperative in 21 and postoperative in 15. Histological examination of the tumor demonstrated basal cell carcinoma in 26 patients and squamous cell carcinoma in 17 patients. Tissue resections were extensive and created large surgical defects, as shown in the following tabulation:Article
The free tissues used to reconstruct these defects were predominantly myocutaneous flaps, as delineated in the following tabulation:Article
Adjunct treatment in the postoperative period included radiation therapy for 15 patients, including the 7 who had not previously received it. Complications are described in the following tabulation:Article
Forty (93%) of 43 flaps were successful.
Twenty-eight of the 43 patients had final tissue margins that were negative, determined by histopathologic examination. Fifteen patients had positive margins, including involvement of a neural structure only in 12.
Despite the massive nature of these cancers and the large resections required, adequate survival was achieved. When considering the entire group, 25 (58%) were alive with no evidence of disease, whereas 18 (42%) had recurrences (12 local, 3 locoregional, and, 3 distant) and were dying or were dead owing to the disease. Perineural invasion was a significant prognostic indicator. Patients with negative margin had a 90% chance of disease survival, whereas those with a positive finding for a perineural invasion had only a 20% incidence of disease survival. Almost all patients with recurrences had local ones (Figure 1). When we apply a 1-factor analysis of variance test with 95% confidence levels to these results, significance was achieved at P<.005.
Facial cancers, like most head and neck cancers, occur predominantly in men. Unlike other mucosal tumors, alcohol and tobacco have little influence in their etiology. Exposure to sunlight is the main predisposing factor. These tumors tended to occur in one of the following settings: recurrence in patients who have received multiple previous treatments, or massive neglected tumor (Figure 2). In our patient population, a significant number of tumors were neglected (13 [30%]). No distinguishing factors separated the neglected from the recurrent groups. Because of the tertiary referral nature of the practice, no conclusions can be drawn about why individuals would leave these tumors to grow to such a size on such a prominent location as the face. Review of the patients with recurrent tumors did not reveal any predisposing factors. In either setting, the tumor involved large cutaneous surface areas. Patients who had been previously treated had large subcutaneous extensions, whereas those with neglected tumors had large fungating lesions. Extensive soft tissue was involved, as well as multiple organ systems (eg, ocular, oromandibular, and olfactory) and the facial skeleton. Adequate removal of these tumors resulted in large complex defects (Figure 3). Complicating the reconstructive dilemma was the high proportion of individuals who had been previously treated with surgery, radiation, or a combination of both. This left the adjacent soft tissues as a poor tissue option for reconstruction of the defect. The composite nature of the tissue loss adds further to the reconstructive dilemma.1, 3-4,6-7 Even in patients with no history of treatment, the soft tissue defects were quite large.
Before the advent of free tissue transfer, local flaps, secondary intention, or regional flaps were used to perform reconstruction. Limitations of these techniques included the arc of rotation, the bulk of the tissue transferred, and the limited ability to contour the flap. Often incomplete resection or a compromised tumor margin resulted.3, 5, 9
The advent of free tissue transfer, with its subsequent proven reliability in head and neck oncologic reconstruction, has made single-stage resection and reconstruction of these composite facial defects possible. The ability to reconstruct these complex defects with similar composite tissue increases the ability of the surgeon to get the best tissue match. Furthermore, it allows the ablative surgeon to perform the resection without regard to tissue preservation. Previously, a consideration in the preoperative evaluation of these lesions was the ability to reconstruct the defect. If a defect could not be reconstructed because of the cosmetic or infectious morbidity, a lesser treatment may have been performed.
One of the requirements for free tissue transfer in these patients is the ability to have the vascular pedicle reach the recipient vessels in the neck. In our series, the rectus abdominis and latissimus dorsi myocutaneous flaps were used to reconstruct most of our defects (Figure 4). These 2 flaps, along with the radial forearm fasciocutaneous flap, have long and large pedicles. Most of the microvascular anastomoses occurred to the facial vessels in the neck. Although other flaps are available that have the same quality and quantity of tissue, adequate pedicle length without the need for vein grafting would not be available. The large size of the cutaneous paddle available and the composite tissue of the latissimus dorsi and rectus abdominis flaps allow them to be oriented in different planes. This allows numerous possibilities for reconstruction of the facial contour (Figure 5). One advantage of the rectus abdominis flap is that it can be harvested at the same time as the initial resection. The latissimus flap requires the patients to be turned on their side. This has not been a determining factor in our practice. Our transfer success rate of 93% matches closely with that of the literature and the success rate in our own general experience.2-3,6-8,11 All reconstructions in our series were performed at the time of the initial resection. Use of a frozen section analysis or Mohs micrographic surgery ensured adequate margins at the periphery of the lesion, and frozen section analysis was used to determine the deep margin status. In our series, the most positive margins occurred in named nerves at the skull base. This finding speaks to the neurotrophic behavior of these massive cutaneous cancers. Subdividing patients into those with and without perineural positive margins revealed a statistically significant difference in survival. A positive finding in the perineural margin at the skull base was a significant poor prognostic indicator. Almost all of these patients had local recurrence and died of their disease.11
Oral rehabilitation was accomplished by reconstructing the hard palate. No patient required an obturator. Cosmetic rehabilitation was problematic in many patients because of the size of the tissue, organ structures, and skeletal structures that were resected.
Patients present with massive cutaneous skin cancers due to recurrence of a previously treated tumor or neglect. Free tissue transfer allows reconstruction of these massive composite tissue defects with reasonable survival and functional rehabilitation.
Corresponding author: Mark K. Wax, MD, Department of Otolaryngology–Head and Neck Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97201 (e-mail: firstname.lastname@example.org).
Accepted for publication November 25, 2002.
This study was presented at the Eighth International Conference on Facial Plastic and Reconstructive Surgery; May 2, 2002; New York, NY.