Facial Skin Cancer Reconstruction

Basics & Goals - Skin Deep Strategy

• Common Facial Skin Cancers:
  • Basal Cell Carcinoma (BCC): Most prevalent, slow-growing.
  • Squamous Cell Carcinoma (SCC): Higher metastatic potential than BCC.
  • Melanoma: Most aggressive, highest mortality.
• Core Reconstructive Goals:
  • Restore normal form and preserve function (e.g., eyelid, lip competence).
  • Achieve optimal aesthetic outcome; minimize visible scarring.
  • Protect vital underlying structures.
• Strategic Principles: 📌 R-A-L-T (RSTL, Aesthetic subunits, Like-with-like, Tension-free)
  • Incisions along Relaxed Skin Tension Lines (RSTL).
  • Reconstruct within facial aesthetic subunits.
  • "Like replaces like": Use tissue similar in color/texture.
  • Tension-free wound closure.
• Timing Considerations:
  • Immediate reconstruction: Preferred for most defects post-excision.
  • Delayed reconstruction: Considered for extensive tumors or after Mohs surgery to ensure clear margins.

⭐ Respecting Relaxed Skin Tension Lines (RSTL) is crucial for minimizing scar visibility and achieving optimal cosmetic outcomes in facial reconstruction.

Defect Assessment & Ladder - Sizing Up Solutions

• Defect Analysis (5 S's):

  • Site: Location, aesthetic subunits (e.g., nasal ala), risk zones (H/M/L).
  • Size & Shape: Dimensions (cm), geometry.
  • Structures (Depth): Skin, subcutaneous, muscle, cartilage, bone.
  • Surrounding Skin: Laxity, vascularity, scars, XRT changes.
  • Special Factors: Functional (eyelid, lip) & cosmetic impact.

• Reconstructive Ladder: Simple to complex.

-   **Options:** Secondary intention → Primary closure → Grafts → Local flaps → Regional/Free flaps.

⭐ High-Yield: Prioritize "like-with-like" tissue replacement & respect aesthetic subunit boundaries for best facial reconstruction.

Local Flaps - Facial Fixer-Uppers

Local flaps use adjacent skin (best color/texture match) for repair. Classified by movement:

• Advancement: Slides forward (e.g., V-Y, rectangular). For small defects.
• Rotation: Pivots around a point (e.g., semicircular). For scalp, cheek.
• Transposition: Lifted over skin into defect.
  • Rhomboid (Limberg): For 60°/120° defects. 📌 "Lazy S".
  • Bilobed: Two lobes, often 90° apart.
  • Z-plasty: Lengthens/reorients scars.
• Interpolation: Pivoted on pedicle (staged).
  • Paramedian Forehead Flap (PMMF): Supratrochlear a.; for large nasal defects.
  • Nasolabial: Cheek to nose/lip.

⭐ Paramedian Forehead Flap (PMMF): Axial flap (supratrochlear a.), workhorse for major nasal reconstruction (tip/ala).

Skin Grafts - Patch & Proceed

• Autologous transfer of epidermis & variable dermis; for defects unsuitable for local flaps.
• Types:
  • FTSG (Full-Thickness): Epidermis + entire dermis.
    • Donors: Postauricular, supraclavicular.
    • Pros: ↓Contraction, better cosmesis.
    • Cons: Needs good bed, limited size.
  • STSG (Split-Thickness): Epidermis + partial dermis.
    • Donors: Thigh, buttock (dermatome).
    • Pros: Large areas, ↑take rate.
    • Cons: ↑Contraction, ↓cosmesis.
• Graft "Take" (Survival) Stages:
  1. Imbibition (Plasmatic): 0-48 hrs (adherence, nutrients).
  2. Inosculation: 48-72 hrs (vessel anastomosis).
  3. Revascularization: >72 hrs (new vessel growth).
• Failure Causes: Poor bed vascularity, infection, hematoma, shear.

⭐ STSG donor sites heal by re-epithelialization from remaining dermal adnexal structures (hair follicles, sweat glands).

High‑Yield Points - ⚡ Biggest Takeaways

• BCC is most common; Mohs surgery for highest cure rate & tissue preservation.
• SCC has higher metastatic risk, especially in immunosuppressed or Marjolin's ulcers.
• Melanoma needs wide excision & SLNB for lesions > 0.8 mm or adverse features.
• Reconstruction uses the reconstructive ladder: direct closure, grafts, local/regional/free flaps.
• Local flaps (e.g., nasolabial, forehead) offer excellent color/texture match.
• Flap choice depends on defect size/location, tissue availability, & patient factors.
• Respecting facial aesthetic subunits is key for optimal cosmesis and scar camouflage.