Evidence-based clinical practice guideline: Reconstruction after skin cancer resection

A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

Large basal cell carcinoma defect closure on the lateral cheek using multiple advancement flaps / Cierre de defecto por carcinoma de células basales en la mejilla lateral usando múltiples flaps de avance

Basal cell carcinoma (BCC) is the most common type of nonmelanoma skin cancer (NMSC). It grows slowly and very rarely metastasizes but can cause substantial morbidity due to its tendency to relapse and locally invasive nature, especially when located on the face. Excision surgery is still the gold standard treatment for primary BCC and is usually followed by reconstruction procedure. Skin flap techniques vary widely, one of which is flap advancement technique. The main benefit of flap advancement technique is the ability to hide the excision line, thus resulting in an aesthetically sound outcome. We report a case of 72-year-old female with hyperpigmented plaque brownish lump on the left lateral cheek. A diagnosis of igmented basal cell carcinoma had been confirmed through histopathological examination. The patient was treated with wide excision surgery and the defectwas closed by multiple advancement flaps. Follow-up after three months showed excellent cosmetic and functional outcome.

El carcinoma basocelular (CBC) es el tipo más común de cáncer de piel no melanoma. Crece lentamente y rara vez hace metástasis, pero puede causar una morbilidad sustancial debido a su ubicación en la cara, tendencia a la recidiva y su comportamiento invasivo local. La cirugía de escisión sigue siendo el tratamiento estándar de oro para el CBC primario y generalmente se acompañan de procedimientos reconstructivos. Las técnicas de flap varían ampliamente, una de las cuales es la técnica de avance del colgajo. El principal beneficio de la técnica de avance es la capacidad de ocultar la línea de escisión y, por lo tanto, se obtiene un resultado más estético. En este artículo reportamos el caso de una mujer de 72 años con placa hiperpigmentada y abultada en su mejilla lateral izquierda. Se había confirmado un diagnóstico de carcinoma de células basales pigmentadas mediante un examen histopatológico. El paciente fue tratado con una amplia cirugía de escisión y el defecto fue cerrado por múltiples colgajos de avance. El seguimiento después de tres meses mostró un excelente resultado cosmético y funcional.

Retalho nasogeniano de interpolação na reconstrução da asa nasal após ressecção de tumores cutâneos / Nasolabial interpolation flap for nasal alar reconstruction after skin tumor resection

Introdução: O nariz é sede frequente de neoplasias cutâneas. Pela importância estético-funcional, a reconstrução do nariz, em especial da asa nasal, é um desafio. O objetivo é descrever o retalho nasogeniano de interpolação na reconstrução da asa nasal após ressecção de tumores cutâneos. Métodos: Pacientes com tumores de pele não melanoma de asa nasal, sem comprometimento dos sulcos alar ou supra-alar, foram submetidos à reconstrução com retalho nasogeniano de interpolação associado a enxerto de cartilagem conchal. Detalhes do planejamento cirúrgico e da sequência operatória, assim como a análise dos resultados, são demonstrados. Resultados: No tratamento de tumores de pele localizados na asa nasal, deve-se buscar resultados sob o ponto de vista oncológico e estético. Assim, a preservação da estrutura tridimensional e das características cutâneas da asa nasal deve ser objetivada. Conclusão: O retalho nasogeniano de interpolação mostrou-se eficaz na reconstrução da asa nasal, apesar da necessidade de dois tempos cirúrgicos.

Introduction: The nose is a common site for skin neoplasms. Due to its functional and esthetic importance, nasal reconstruction, mainly that of the nose ala, is challenging. The objective is to describe the nasolabial interpolation flap for nasal alar reconstruction after skin tumor resection. Methods: Patients with nonmelanoma skin tumors on the nasal ala without involvement of the alar and supra-alar sulcus underwent reconstruction with a nasolabial interpolation flap associated with conchal cartilage grafting. Details of the surgical planning and operative sequence and an analysis of the results are presented. Results: In the treatment of skin tumors on the nasal ala, results from the oncological and esthetic point of view should be sought, i.e., maintenance of the threedimensional structure and cutaneous features should be intended. Conclusion: Use of the nasolabial interpolation flap was effective for nasal alar reconstruction despite the need for two surgeries.

Allogeneic hematopoietic stem cell transplantation for refractory mycosis fungoides (MF) and Sezary syndrome (SS).

Cutaneous T cell lymphoma is a heterogeneous group of lymphoproliferative disorders with different clinical behavior and prognosis in which malignant T cells accumulate in the skin. In the relapsed/refractory stage, treatment strategy varies depending on clinical perspective. We retrospectively evaluated advanced stage relapse or refractory mycosis fungoides and Sezary syndrome patients who underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT) at our hospital. The overall response rate was 25%, while the disease progressed and relapsed after transplant in 38% of patients. Allo-HSCT may be a reasonable treatment option in the relapsed/refractory stage.

Impact of Cosmetic Camouflage on the Quality of Life of Children With Skin Disease and Their Families.

BACKGROUND/OBJECTIVES: Cosmetic camouflage is known to improve quality of life in adults. Few data are available regarding cosmetic camouflage in children, and thus it is not often selected as a mode of treatment. We sought to determine whether cosmetic camouflage leads to improved quality of life of pediatric patients with visible dermatoses and their parent or primary caregiver. METHODS: Patients aged 5 to 17 years with visible skin disease and their parent were assessed with the Children's Dermatology Life Quality Index (CDLQI) and the Family Dermatology Life Quality Index (FDLQI) before and after consultation regarding cosmetic camouflage. RESULTS: Twenty-two children with skin conditions were included in the study. The mean CDLQI decreased from 6.82 (SD = 1.28) to 3.05 (SD = 0.65; P = .0014), while the mean FDLQI decreased from 7.68 (SD = 1.15) to 4.68 (SD = 0.92; P = .0012). CONCLUSIONS: Our study highlighted improvement in quality of life in patients with skin disorders who were managed with cosmetic camouflage.

Effects of web-based intervention on risk reduction behaviors in melanoma survivors.

PURPOSE: Melanoma is the most severe form of skin cancer, and survivors of melanoma carry increased risk of additional melanoma diagnosis. Multiple methods exist for primary and secondary prevention of melanoma in survivors. This study tested a web-based family communication intervention to improve these preventive behaviors in melanoma families. METHODS: Families (a survivor, at least one first-degree relative and a parent) were randomized either to receive the intervention package or to serve as comparison families. We assessed melanoma prevention behaviors in each cohort member before and after the intervention. The intervention was a web-based multicomponent intervention focused on increasing family communication and exchange of risk information. RESULTS: Results indicated that, compared to comparison survivors, intervention survivors improved their skin self-examination and their sun protection behaviors significantly from before to after intervention. CONCLUSION: These data support the use of web-based interventions for behavioral changes in survivors and allow for consideration of dissemination of this successful intervention. These data have implications for interventions that can help cancer families deal with issues of risk and illness. IMPLICATIONS FOR CANCER SURVIVORS: These data indicate that survivors can benefit from exposure to a website that helps direct their future health behaviors.

Prosthodontic rehabilitation of a patient using a swing-lock lower denture after segmental mandibulectomy.

A swing-lock denture is useful in partially dentate patients where the configuration of the remaining teeth means that either the retention or stability available for a conventional removable partial denture is compromised. Such removable prostheses can also prove to be extremely useful when providing prosthodontic rehabilitation following surgical resection of oral cancer. A 20 year-old patient was referred to the Restorative Department of Cork University Dental Hospital following segmental mandibulectomy to treat a calicifying epithelial odontogenic tumour (Pindborg Tumour). Initial treatment using a conventional lower partial denture failed. This paper outlines the successfully rehabilitation using a lower Cobalt-Chromium swing-lock partial denture.

Xeroderma pigmentosum with melanoma of face and its prosthetic management.

Xeroderma pigmentosum is a rare genetic disorder, characterized by cutaneous, ocular and neurological symptoms. Squamous cell carcinoma and melanoma are also its secondary characters. This case report is about maxillofacial prosthetic management of a 10 years old child presented with xeroderma pigmentosum. The nose of the patient was excised surgically due to melanoma. This case report elaborates the role of prosthodontist and the whole procedure of constructing the nasal prosthesis via conventional technique by using the patient's sibling nasal form as template. Regular follow up revealed marked improvement in esthetics, function and ultimately patient's quality of life.

Tumor cutâneo em parede nasal lateral e as opções de retalhos cutâneos para reconstrução após ressecção neoplásica / Nasal wall skin tumors and flap options for reconstruction after neoplasm resection

Introdução: As perdas de substâncias da parede nasal lateral são comuns, sendo causadas principalmente por ressecção de neoplasias de pele. Existem muitas alternativas para cobertura cutânea e os retalhos cutâneos representam as melhores opções tanto cosméticas como funcionais. Métodos: Foi realizada uma análise de 25 retalhos cutâneos nasais utilizados para reconstrução de perdas de substâncias da parede nasal lateral, secundárias à neoplasia, nos pacientes operados no Serviço de Cirurgia Plástica do Hospital São Lucas-PUCRS no período de dezembro de 2008 a dezembro de 2011. Resultados: A maioria dos pacientes foi do sexo masculino (60%) e a idade média foi de 66,55 anos. A maioria dos tumores cutâneos eram carcinoma basocelular (92%). O retalho mais utilizado foi o retalho de avanço em V-Y(72%), seguido do retalho bilobado (16%). Em 8% foi utilizado o retalho glabelar e em 4% o glabelar extendido. Conclusão: São múltiplas as opções cirúrgicas na reconstrução da parede nasal lateral após cirurgia oncológica, devendo-se escolher a mais adequada para cada caso, respeitando-se os contornos e a anatômia nasal de acordo aos princípios de Burget e Menick, além dos princípios oncológicos (AU)

Introduction: Losses of the lateral nasal wall are common and mainly caused by resection of skin neoplasms. There are many alternatives to cover skin, and skin flaps represent the best cosmetic and functional options. Methods: We performed an analysis of 25 skin flaps used for reconstruction of nasal losses of the lateral nasal wall, secondary to malignancy in patients operated at the Department of Plastic Surgery, Hospital São Lucas (PUCRS) from December 2008 to December 2011. Results: Most patients were male (60%) and the mean age was 66.55 years. Most cutaneous tumors were basal cell carcinoma (92%). The most often used flap was further advancement flap in VY (72%), followed by the bilobed flap (16%). Glabellar flap was used in 8% and extended glabellar in 4%. Conclusion: There are multiple surgical options for nasal wall reconstruction after cancer surgery, and one should choose the most suitable for each case, respecting the outlines and nasal anatomy according to the principles of Burget and Menick, in addition to oncological principles (AU)

Rhinectomy for the management of nasal malignancies.

BACKGROUND: Tumours of nasal skin or mucosa are common, and can usually be treated with limited surgical excision or radiotherapy. This paper highlights a subset of high risk tumours which require rhinectomy for complete oncological clearance. METHOD: Retrospective case note review of 14 patients undergoing rhinectomy for nasal tumours. Clinical and histological findings, treatment and outcome are reviewed and discussed. RESULTS: Forty-three per cent of patients had recurrent disease and underwent rhinectomy as a salvage procedure following previous surgery or radiotherapy. Most tumours (79 per cent) were basal cell carcinoma or squamous cell carcinoma. After a mean follow up of 30.1 months (range, zero to 96 months), seven patients (50 per cent) were alive and disease-free. Reconstruction was most commonly with a prosthesis. CONCLUSION: Rhinectomy is an oncologically sound procedure for the management of high risk nasal malignancies. Prosthetic rehabilitation can be an excellent alternative to surgery, particularly in those patients unsuitable for major reconstruction.

Sickness absence and full return to work after cancer: 2-year follow-up of register data for different cancer sites.

OBJECTIVE: Cancer survival has improved in recent years, but data on return to work (RTW) after cancer are sparsely published. Therefore, this study analysed RTW after cancer. METHODS: Employees diagnosed with breast cancer, genital cancer, gastro-intestinal cancer, lung cancer, skin cancer, or blood malignancies were selected from an occupational health register. Sickness absence was followed for 2 years after diagnosis and full RTW at equal earnings as before sickness absence was assessed for each cancer site using Cox proportional hazards regression analysis stratifying for age and gender. RESULTS: 3701 (73%) of 5074 employees with cancer had full RTW after a median duration of 290 days. Employees with lung cancer had the longest duration of sickness absence and only 45% of them had full RTW 2 years after diagnosis compared with 88% of employees with genital cancer and 87% of employees with skin cancer. Age was associated with the time to full RTW among employees with genital cancer: women aged≥35 years had a longer time to full RTW compared with women <35 years and men aged≥55 years had a longer time to full RTW compared with men <35 years. Gender was associated with the time to full RTW among survivors of blood malignancies with women having a longer time to full RTW than men. CONCLUSIONS: Most employees had full RTW within 2 years after the diagnosis of cancer and the time to RTW was largely independent of age and gender.

An algorythmic approach to restoration of the fronto-naso-periorbital skin defects using the forehead flaps.

BACKGROUND AND OBJECTIVE: The classic forehead flaps, which are designed vertically, two-staged and exteriorised pedicled peninsular flaps, are still a reconstructive option for nasal and periorbital defects. However, some drawbacks such as conspicuous donor-site scar, multi-staged procedure, rather short pedicle, hairy appearance (in narrow foreheads), and inability to use the forehead flap when the donor site is involved are often encountered during surgery. To avoid these issues, three unusual designs of the forehead flap are presented, and also a new algorithm is proposed to guide surgeons in their solutions. MATERIALS AND METHODS: Nineteen patients (10 women and nine men) were managed with 21 forehead flaps to restore the nasal, medial canthal and frontal defects caused by skin tumours. The flaps were applied as interpolation island, V-Y island, and transverse peninsular designs in 12, four and three patients, respectively. All donor sites were closed primarily except one, where a split thickness skin graft was used. RESULTS: The average follow-up was 14 months. All flaps survived (totally) but in one partial necrosis developed. Aesthetic and functional recoveries were acceptable in all patients. CONCLUSIONS: Based on the algorithm presented, the forehead flaps with their superb anatomic characteristics including rich vascular supply and pliable skin can be safely used in either classic or extraordinary fashion for small to medium sized defects of the nasoorbital and frontal regions.

Skin cancer: follow-up, rehabilitation, palliative and supportive care.

Follow-up, rehabilitation and palliative/supportive care are essential parts of the care and treatment of skin cancer patients. This review provides an overview on the state of knowledge and recent developments in these three disciplines, hereby providing standard operating procedures for the dermatologist in the care of skin cancer patients. Especially in follow-up and supportive care, the results of recent clinical trials have led to significant changes in the standard of care. These new insights and their consequences are the special focus of this article.

A comparative study on superior auricular artery island flaps with various pedicles for repair of periorbital defects.

Superior auricular artery (SAA) island flaps elevated from the retroauricular region have perfect color, thickness, and texture match with facial skin. In this article, reconstruction of periorbital defects with SAA island flaps is presented. Flaps were categorized into three types because they were elevated on three different pedicles. A type 1 flap was a superficial temporal vessel pedicled SAA island flap with antegrade blood flow. A type 2 flap was a reverse flow SAA island flap based on the frontal branch of the superficial temporal artery (STA). A type 3 flap was a reverse flow SAA island flap based on the parietal branch of STA. Fourteen patients (9 females and 5 males) aged between 31 years and 74 years were treated with these flaps. Two patients with lower eyelid, two patients with upper eyelid, three patients with malar, two patients with infraorbital, one patient with lateral canthal upper eyelid, and four patients with forehead defects underwent surgical intervention. Sizes of the flaps varied between 3x6 cm and 8x6 cm. Venous congestion was observed in all patients in the early postoperative period and lasted for 5 to 9 (mean, 6.6) days in type 1 flap, 5 to 9 (mean, 6.7) days in type 2 flap, and 2 to 5 (mean, 3.6) days in type 3 flap. Apart from distal necrosis of 1x1 cm in one patient and superficial dermal sloughing in two patients, no complications were encountered. Aesthetically and functionally successful results with minimal donor site morbidity were obtained in all patients during the 2 to 22 (mean 10.8) month follow-up period.