Skin cancer and its management

Skin cancer is very common in Australia and New Zealand . The predominantly Celtic background of the population, combined with an outdoor lifestyle and sun exposure is the major predisposing cause of skin malignancy.

Fortunately, over a period of 20 years of public education, extensive malignancy is uncommon and the challenge is to detect skin malignancy in its early stages and treat it so that there will be no recurrence. The problem that exists with all skin malignancies, is if they recur, their management is much more difficult. The golden standard of management of skin malignancy is surgical resection.

Proof of the adequacy of the surgical resection requires histological confirmation by Histopathologists (Pathologists) that the removal of the malignancy is complete. The other great challenge of surgical resection is the repair. All patients fear, rightfully so, that surgery means scarring. By combining the skills of a plastic surgeon interested in the cosmesis of repair, the deformities of even significantly large resections can be minimized, allowing a patient to go unnoticed in society, rather than have the stigmata of surgical resection and repair on their face or body. Mohs’ technique and frozen section techniques are two varieties of the methods used by Pathologists to determine microscopically that the malignancy is removed completely.

Classification of Skin Malignancy

There are three basic classifications of Skin Malignancy: Basal Cell Carcinoma, Squamous Cell Carcinomas and Melanomas. The treatment of all these differs significantly.

1. Basal Cell Carcinomas can usually be resected with a small margin of normal tissue and they do not metastasize (spread widely) (Figure 6, Figure 7).
   

   Figure 6

   Figure 7

2. The problem with Squamous Cell Carcinomas is that they have a tendency to spread to the regional lymph nodes and then possibly to distant sites. (Figure 8, Figure 9).
   

   Figure 8

   Figure 9

   
   Hence, treatment in the early stages is important. Surgical resection with histological control in smaller, moderate sized lesions 2 cm to 4 cm in size is required. It is necessary to have total removal of the malignancy confirmed.
   Lesions that have already caused spread to the lymph nodes (T3 lesion) require specialized treatment of the nodal areas, likely nodal resection. Lesions that have spread throughout the body, require oncological management with either radiation or chemotherapy.
3. Melanoma is the most potentially lethal of skin malignancies. They have a variety of different presentations; either a mole has changed or a new pigmented lesion has changed to black, blue or red may be a melanoma. Not all melanomas arise in moles. Some moles called dysplastic naevi have a high potential to become malignant and can be multiple. These moles may proceed on to become a malignant melanoma. A mole scan is helpful in following moles to determine if they have changed in size or colour. A change can represent malignant transformation. (Figure 10, Figure 11, Figure 12).
   

   Figure 10

   Figure 11

   Figure 12

   
   The treatment of the melanoma depends on the thickness of the melanoma as measured by the Histopathologist using microscopic evaluation.
   The management of malignant melanoma is to excise the suspicious lesion, send it to the Pathologist so it can be accurately diagnosed as to its thickness and depth of invasion after which the surgical plan of management can be designed. This often involves more resection to remove adjacent skin so as local recurrence rates can be reduced.
   To determine whether lymph nodes need to be removed, a “Sentinel Node” Scan can to be done to identify the lymph node drainage area of the melanoma and if positive, this indicates the nodal region should be surgically removed also.

The Surgical Management of Skin Cancers

The surgical management of skin cancers depends on the site where the skin cancer occurred. At all costs, we try to minimise scarring and the sequelae of the surgical removal and repair. Every area requires special consideration and the options of surgical repair include:

• Simple excision and closure.
• A skin graft.
• Excision and closure with a flap (sliding in tissue from adjacent areas).
• Distant flap reconstruction.
• Expansion techniques.
• Free flap reconstruction.

As a general principle, we try not to use skin grafts for reconstruction, as they are thin, do not match in colour or texture and give a poor patch-like appearance. We prefer to use local flaps which have the same texture, thickness and colour as the area from which the skin malignancy is removed. These are provided by local flaps or expansion technique.

Skin Cancers of the Scalp

Skin cancers of the scalp are nearly always a ba sal cell cancer and require excision with histological control by a pathologist using frozen section and then reconstruction. Small lesions up to 1 cm can be closed primarily. Skin cancers that are over 1 cm require flap reconstruction. The scalp is very rigid and resists stretching and movement; hence flaps need to be usually quite large and often a rotation flap is used. An example of such a rotation flap is seen. (Figure 23, Figure 24).

Figure 23

Figure 24

Skin Cancers of the Forehead

In the forehead, lesions over 1 cm require flap reconstruction. In the forehead, we have to be careful not to distort the eyebrows and to align all the incisions with the natural forehead horizontal wrinkles. Advancement flaps are often used here to bring the tissue into alignment. An example is shown: (Figure 32)

Figure 32

Skin Cancers of the Ear

Skin cancers of the ear require creative techniques in order to maintain the appropriate shape of the ear. Small tumours less than 5 mm can be excised directly and primarily closed. If the tumour is 1 cm or more, especially on the helix or rim of the ear, a pentagonal excision can be carried out to maintain the shape of the ear but the ear remains slightly small. Resurfacing the front of the ear can be done with a flap from the ba ck of the ear and passed forward (a flip-flop flap). More complicated flaps are required for more complex deformities. (Figure 43, Figure 44).

Figure 43

Figure 44

Skin Cancers of the Nose

Skin cancers of the nose are quite common and a skin graft here is cosmetically unacceptable. For smaller lesions, up to 1 cm, a transposition flap called a ba nner flap or bi-lobed flap is used. We lift up the skin and it slides around to fill the defect with incisions hidden in a less noticeable area on the side of the nose. (Figure 73, Figure 74, Figure 75, Figure 76, Figure 77).

Figure 73	Figure 74	Figure 75
Figure 76	Figure 77

For more extensive skin cancers, where there is loss of structure of the nose, then a forehead flap can be used. This is a more extensive procedure where tissue from a distant area but with like colour of the forehead, is brought down and placed on the nose after the nasal structures, including lining and cartilage have been restored. (Figure 78, Figure 80).

Figure 78

Figure 80

Skin Cancers of the Eyelid

Eyelid skin cancers if less than 5 mm can be removed by direct excision but care must be taken not to distort the eyelid margin or in the lower lid cause ectropion (hanging down of the lower lid) causing dryness of the eyes.

Larger lesions over 5 mm, require flap reconstruction sliding in tissues from the side, from the cheek or the temporal region or sharing skin from the upper lid to the lower lid, in order to reconstruct the defect.

More complex defects which involve the eyelid margin and not the skin alone, require more complicated reconstructions with the provision and the structural integrity of the tarsal plate as well as the lining (the conjunctival lining).

Skin Cancers of the Lips

Upper lip malignancies require excision and care must be taken not to distort the margin of the lip; in particular the cupid’s bow or the rolled white line. The height of the lip must be maintained. Simple wedge excisions can be done for deep lesions up to 1 cm in width or one quarter of the width of the lip. For defects which are greater, a lip switch procedure called an Abbe flap is performed. This flap moves tissues from the lower lip up into the upper lip where they bridge and this stays in place for approximately two to three weeks, after which it is severed and the upper lip maintains its shape, rather than becoming tight.

Similarly, on the lower lip, tissue can be shared or tissue can be moved around from the cheek area by a procedure called the Karapanzic procedure which effectively makes a smaller but better shaped mouth. An example is seen. (Figure 50, Figure 59, Figure 64, Figure 65).

Figure 50

Figure 59

Figure 64

Figure 65

Skin Cancers of the Cheeks

Cheek advancement flaps are used with perialar excision in order to move cheek skin over to the upper lip. An example is seen.

On the cheek, excisions up to 1 cm are satisfactory and leave a linear incision which can be repaired and should lie in the lines of skin relaxation.

Defects larger than 1 cm require reconstruction. Popular reconstruction includes the V to Y flap and the rhomboid flap. The V to Y flap is an advancement flap; the rhomboid flap is a transpositional flap. Larger defects on the cheeks can be resurfaced from the neck. A larger defect using the neck flap skin can be carried on the platysma muscle as an island flap. An example is seen. (Figure 113, Figure 114, Figure 115, Figure 116, Figure 117).

Figure 113	Figure 114	Figure 115
Figure 116	Figure 117

Skin Cancers of the Neck.

On the neck, surgical excision along the horizontal neck lines is satisfactory and for even larger lesions up to 2 cm to 3 cm.

Skin Cancers of the Trunk and Limbs

On the trunk, scars are less obvious. Larger lesions up to 2 cm to 3 cm can be closed primarily as they can on the limbs.

If lesions on the trunk and limbs cannot be closed primarily, then the same variety of flaps, advancement, V to Y and transposition flaps, including rhomboid are used.

Expansion Techniques

For large lesions, expansion is an excellent way of reconstructing the large defect, restoring a whole aesthetic unit. By expansion, we mean a balloon is placed underneath the skin in the adjacent areas, expanded and pumped up for up to two months, hence growing skin. Then flaps are elevated and the flap slides into place as an advancement or rotation flap.

Patients need to understand and tolerate the ‘ ba lloons’; often there is more than one. This gives the best result for a large defect without a change in the colour or texture of the skin which is inevitable from distant and microvascular flaps. (Figure 126, Figure 127, Figure 128).

Figure 126

Figure 127

Figure 128

Free Flaps

Free flaps require microscopic sections and are for the most extensive, neglected malignancies. Fortunately, in our society, these flaps are rarely needed. I have needed to do three or four free flaps in the 25 years I have been treating skin malignancies in Australia and in the United States .

Conclusion

This overview of reconstruction of options aims to give the patient with skin malignancy a realistic view of potential for cure and cosmetic restoration. For more information regarding these procedures and to see Dr Hodgkinson in print regarding skin malignancy, you can contact www.cosmeticsurgeryoz.com

DR DARRYL J. HODGKINSON - Plastic Surgeon

M.B. B.S. (Hons) F.R.C.S. (C) F.A.C.S.