Skin Cancer Treatment

Contents
Preface: State-of-the-Art in Skin Cancer Surgery xiii
Jeffrey S. Moyer

Nonmelanoma Skin Cancer 1

Michael G. Brandt and Corey C. Moore

This article reviews the most common nonmelanoma skin cancers affecting the head
and neck region. Although the most common of these malignancies rarely result in
mortality, local morbidity caused by the tumors and their extirpation cannot be
underestimated. Complete tumor extirpation with pathologically confirmed negative
margins is the gold standard. Regional and distant metastases are rare, but must be
treated appropriately should they occur. Although reconstructive surgery can be life
changing for the patients and rewarding for the clinicians, it behooves the treating
surgeons to remain true to oncologic principles above all else.

Mohs Micrographic Surgery 15

Emily Wong, Eileen Axibal, and Mariah Brown

Mohs micrographic surgery (MMS) is the gold standard for treating various cutaneous
tumors. MMS has evolved into a single-day, outpatient procedure. The tumor is
excised, mapped, and processed with frozen, horizontal sections for immediate his-
tologic evaluation. The process is repeated as necessary until the tumor is completely
removed, with maximal conservation of normal tissue. Evaluation of 100% of the sur-
gical margin allows for exceptional cure rates. The Mohs surgeon is trained in
tumor excision, histopathology interpretation, and surgical reconstruction. The use
of MMS is often part of a multidisciplinary approach to treating cutaneous tumors.

Management of Early-Stage Melanoma 35

Maria J. Quintanilla-Dieck and Christopher K. Bichakjian

Melanoma is a potentially aggressive skin cancer with a steadily rising incidence.

Most melanomas are diagnosed at an early stage and associated with an excellent
prognosis when treated appropriately. Primary treatment for melanoma is surgical.
Wider surgical margins and a variety of techniques for comprehensive histologic
margin assessment may be considered for lentigo maligna type melanoma on the
head and neck, due to characteristic broad subclinical extension. For invasive mel-
anoma, sentinel lymph node biopsy may be indicated for staging, and to guide
further management and follow-up. Appropriate treatment guidelines for early-
stage melanoma are reviewed and discussed.

Reconstruction of the Nose 43

Andrew W. Joseph, Carl Truesdale, and Shan R. Baker

Nasal reconstructive techniques have advanced significantly over the past 50 years.
Modern techniques in nasal reconstruction are based on the nasal aesthetic sub-
units. In order to achieve ideal outcomes, reconstructive surgeons must consider
differences in tissue qualities across the nasal aesthetic subunits and formulate
reconstructive plans based on these differences. Local flaps, skin grafts, and several
types of interpolated flaps comprise the most commonly used techniques for nasal

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viii Contents

reconstruction. Defects that involve structural or internal lining defects require

reconstruction of significantly higher complexity.

Reconstruction of the Cheek 55

Nathan D. Cass and Adam M. Terella

The goal of cheek reconstruction is to restore an illusion of “normal.” Attention must

be directed toward the contralateral cheek skin color, texture, thickness, and con-
tour, because this serves a template for reconstruction. The cheek is a peripheral
facial subunit and largely frames the more central subunits (eyelids, nose, lips). As
such, avoiding distortion or disfigurement of the central subunits is of paramount
importance. The cheek possesses significant tissue laxity, elasticity, and mobility,
thus allowing for the vast majority of cheek defects to be addressed with primary
closure, local flaps, or locoregional flaps.

Reconstruction of Defects Involving the Lip and Chin 67

Katie Geelan-Hansen, Joseph Madison Clark, and William W. Shockley

Successful perioral reconstruction is the result of consideration of both functional

and esthetic goals. The lips are complex esthetic units with multiple tissue layers
and distinct anatomic landmarks. Reconstruction can be difficult due to variables
affecting the defect, such as size, depth, location, and involvement of adjacent sub-
units. There are many local flaps that can be used to match the complex tissue layers
and anatomic landmarks. Use of the same reconstructive principles can be applied
to secondary reconstruction to attain a successful outcome. This article focuses on
local reconstructive options for defects of the lip and chin.

Reconstruction of the Forehead and Scalp 85

Benjamin D. Bradford and Judy W. Lee

Tissue inelasticity and the hair-bearing nature of the scalp and forehead pose unique
challenges during reconstruction. A thorough understanding of the surgical anatomy
of the scalp and forehead is paramount for optimal reconstructive outcomes. Pri-
mary wound closure is usually preferred over secondary intention healing and skin
grafting. Use of dermal alternatives and tissue expansion are adjunctive therapies
to facilitate scalp wound closure. Local skin and soft tissue flaps are commonly
used for most small to medium defects; however, microsurgical free tissue transfer
can be considered for large full-thickness skin defects of the forehead and scalp.

Reconstruction of the Ear 95

Ryan M. Smith and Patrick J. Byrne

Skin cancer is a common indication for reconstructive surgery of the ear. The unique
anatomy of the external ear makes the restoration of form and function challenging for
the reconstructive surgeon. This article reviews the relevant anatomy of the ear, de-
fines the goals of reconstruction, outlines the assessment of defects based on loca-
tion, and describes specific surgical techniques useful in auricular reconstruction.

Periocular Reconstruction 105

Kira L. Segal and Christine C. Nelson

Options for periorbital reconstruction include primary wound closure, local flaps,
regional/distant flaps, or full-thickness skin grafts. Optimal aesthetic and functional

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 Contents ix

outcomes are achieved by assessing regional contours, skin type, and facial
aesthetic units. Like tissue should replace like tissue; for example, skin with skin,
tarsus with tarsus (or equivalent material, eg, hard palate, ear cartilage, or autolo-
gous substitute), and conjunctiva with mucous membrane or like substitute (buccal
mucous membrane, amniotic membrane). Patient characteristics including wound
care needs, transportation needs, smoking status, and history of radiation can influ-
ence the reconstruction plan. Techniques most commonly used in our practice are
reviewed.

The Role of Sentinel Lymph Node Biopsy in the Management of Cutaneous

Malignancies 119
Faisal I. Ahmad, Shirley Y. Su, and Neil D. Gross

Sentinel lymph node biopsy uses the concept of selective lymphatic drainage and
the lymphatic microvasculature to identify first-echelon nodes draining a given ma-
lignancy. Although initially considered difficult and unreliable in the head and neck,
experience with the technique has improved and evolved significantly over the last 3
decades. It is now recognized to be accurate and reliable for regional nodal staging
and detection of occult nodal metastasis in the head and neck. Although initially
described for nodal staging of melanoma, the usefulness of sentinel lymph node bi-
opsy continues to expand and is now extended to other cutaneous malignancies as
well as mucosal malignancies of the oral cavity and oropharynx.

Radiotherapy for Skin Cancers of the Face, Head, and Neck 131
Michelle L. Mierzwa

Radiotherapy plays a role in the definitive or adjuvant management of early and late
stage skin cancers including nonmelanoma basal cell carcinoma and cutaneous
squamous cell carcinoma, melanoma, and Merkel cell carcinoma. The role of radio-
therapy in skin cancers of the head and neck is reviewed including early and
advanced-stage nonmelanoma skin cancers, melanoma, and Merkel cell carci-
noma. In particular, the indications, oncologic outcomes, and technical aspects of
radiotherapy for these diseases are discussed.

Adjuvant and Neoadjuvant Treatment of Skin Cancer 139

Assuntina G. Sacco and Gregory A. Daniels

Skin cancer represents a broad classification of malignancies, which can be further

refined by histology, including basal cell carcinoma, squamous cell carcinoma and
melanoma. As these three cancers are distinct entities, we review each one sepa-
rately, with a focus on their epidemiology, etiology including relevant genomic
data, and the current evidence-based recommendations for adjuvant and neoadju-
vant therapy. We also discuss future directions and opportunities for continued ther-
apeutic advances.

Tissue Engineering and 3-Dimensional Modeling for Facial Reconstruction 151

Kyle K. VanKoevering, David A. Zopf, and Scott J. Hollister

Three-dimensional (3D) printing has transformed craniofacial reconstruction over the

last 2 decades. For cutaneous oncologic surgeons, several 3D printed technologies
are available to assist with craniofacial bony reconstruction and preliminary soft
tissue reconstructive efforts. With improved accessibility and simplified design

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x Contents

software, 3D printing has opened the door for new techniques in anaplastology. Tis-
sue engineering has more recently emerged as a promising concept for complex
auricular and nasal reconstruction. Combined with 3D printing, several groups
have demonstrated promising preclinical results with cartilage growth. This article
highlights the applications and current state of 3D printing and tissue engineering
in craniofacial reconstruction.

Health Outcome Studies in Skin Cancer Surgery 163

Cristen E. Olds and Jon-Paul Pepper

As cutaneous cancers are the most common malignancies affecting US citizens,

they represent a significant public health problem and health care cost burden.
There are a variety of treatment options available to manage cutaneous malig-
nancies, but limited data are available regarding outcomes, including quality of
life, recurrence, and mortality. Here, we examine outcomes of skin cancer surgery
as they relate to sociodemographic data and treatment factors.

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