1. Non-melanoma skin cancer reconstruction of the head and neck region at Northampton General Hospital: a case series. Iqbal U1, Kapasi F2 Ameerally P3
1 Dental Core Trainee in Oral and Maxillofacial Surgery, Northampton General Hospital, UK 2 Specialty Trainee in Oral and Maxillofacial Surgery, Northampton General Hospital UK 3 Consultant Oral and Maxillofacial Surgeon, Northampton General Hospital, UK
Background
Case 2
84 year old female with a previous history of SCC presented with a new lesion at site of previous surgery.
Radiological and pathological investigation confirmed a diagnosis of Merckel cell carcinoma of the right cheek with bony infiltration into the orbit.
MDT approach was used in conjunction with Dermatologists and Oculoplastic Surgeons.
She had a wide local resection of the tumour which included the right cheek, nose, lip and right orbital exenteration.
She had a cervical rotation flap to reconstruct the cheek, nose and lip. A bipedicled scalp flap was used to reduce the size of the cheek defect. She had multiple split skin grafts to reconstruct the orbital floor. A prosthetic eye was fabricated by the prosthetics team.
She had post-operative radiotherapy.
Non-melanoma skin cancers (NMSC) are the most common group of cancers in England.
The most frequent types are basal cell and squamous cell carcinomas, but the group also includes a number of rare cancers such as Merkel cell carcinoma.
Sun exposed areas in the head and neck are most affected, this means that the nose, lip and ears are at greater risk of developing disease.
These areas present with significant reconstructive challenges for the surgeon: the disease must be fully resected and the areas for reconstruction tend to be in areas of high visibility with difficult morphology to reconstruct.
Pre-operative
15 months Post-op
Case 1
Discussion
85 year old male presented with a 10mmx8mm tender keratotic lesion on the left nasal bridge of several years history.
Radiological and pathological investigation confirmed a diagnosis of recurrent squamous cell carcinoma.
The lesion included his left cheek with invasion into the nasal bones and orbital cavity.
MDT approach was used in conjunction with Dermatologists and Oculoplastic Surgeons.
He had a total rhinectomy involving the left orbital floor and resection of the medial wall, left cheek and forehead skin.
The orbital floor was reconstructed with a paramedian forehead flap. The eyelids were reconstructed with local rotational skin flaps. A prosthetic nose was fabricated by the prosthetics team.
He had post-operative radiotherapy.
This case series highlights the reconstructive challenges of skin cancer treatment in the Head and Neck.
A Multidisciplinary Team approach comprising Dermatologist, Oral and Maxillofacial Surgeons, Plastic Surgeons, Dermatologists, Histologists and Prostheticians was key in achieving the best functional and aesthetic outcomes for these patients.
Multiple techniques were used in reconstruction including skin grafts, local flaps and prostheses.
Other reconstructive techniques include allowing the orbit to heal by secondary intention which requires frequent dressings with antibacterial packs. This technique usually results in a shallower socket which may prove problems when considering an orbital prosthesis. Another technique is the use of a vascularized flap such as a transposed forehead flap to fill the orbit. Free tissue transfers have also been used.
We hope that this case series has provided a good insight into the outcomes that can be achieved in patients with NMSC in difficult areas.
Pre-operative
15 months Post-op
Case 3
An 86 year old gentleman was referred by Ophthalmology with a basal cell carcinoma of the right nose, cheek and infiltrating the right eye. The patient already had pre-existing blindness.
He had a rhinectomy, right orbital exenteration and wide local excision of extensive basal cell carcinoma. Local advancement flaps were used to close the defect at the lateral nasal margins. The eyelids were preserved to form the lateral orbital wall. A split-skin graft was taken from the left thigh to further cover the orbital defect.
References
Goldberg et al. Orbital exenteration: results of an individualised approach. (2003)
Chepeha et al. Restoration of the orbital aesthetic subunit in complex mid facial defects. (2004)
Pre-operative
7 months Post-op