Skin cancer is the most common type of cancer affecting humans and is most commonly caused by cumulative sun exposure throughout a person’s lifetime. Skin that is exposed to sunlight is the most susceptible to skin cancer formation, making the face one of the most likely sites for skin cancer to develop. The three main types of skin cancer include basal cell carcinoma, squamous cell carcinoma, and melanoma. The severity of these cancers can range from very small, superficial lesions that can be cured with topical or cryotherapy to large, invasive tumors that can spread throughout the body and require extensive surgical resection and potentially even radiation or chemotherapy. For this reason, all suspicious skin lesions or areas of ulceration that do not heal should be taken seriously and evaluated promptly.
While many early or pre-cancerous lesions can be treated effectively by dermatologists with topical or non-surgical treatments, more advanced skin cancers require surgical excision for treatment. This poses a particular challenge for skin cancers on the face where scars may be easily visible and have a high impact on facial appearance. Skin cancers on the face are often excised using the Mohs technique. This is performed by specially trained dermatologists who remove the tumor and examine the tissue under the microscope to assure that all the cancer is removed. This technique spares the most amount of normal skin around a cancer and has the lowest rate of recurrence; two factors that are vital for skin cancers involving the face. Once the cancer is removed, there remains the challenge of how to reconstruct the resulting defect without compromising facial aesthetics or function. Facial plastic and reconstructive surgeons are particularly well suited for this type of reconstruction due to their training in plastic surgery techniques and dedication of their practice to only the face, head, and neck.
Goals of Skin Cancer Reconstruction
Patients suffering from skin cancer of the face have a very difficult challenge. Not only do these patients have to deal with cancer, but the treatment and removal of that cancer affects the very feature that defines their identity; their face. Unfortunately, the damage caused by skin cancer can never be completely undone, and no surgery on the skin can be performed without leaving a scar. However, reconstruction of facial skin cancer defects should aim to return the individual’s facial form and function to as close to normal as possible so that individual is not left with permanent consequences from a cured skin cancer.
Wound healing is a complicated process that often takes up to 1 year for complete maturation of scars to occur. During this time, there may be a period when scars initially look worse before they look better. A completed final result may take more than one procedure or require small “touch ups” with various scar revision treatments to optimize the final appearance. All of this is factored in to the selection of the reconstructive method chosen through a thorough discussion between the patient and surgeon. The ultimate goal is to allow patients to return to their normal daily life without having to worry about how others view their face; without limiting daily function or social interactions. Although the experience of skin cancer cannot be erased, the goal of facial reconstruction is to avoid a permanent reminder of the cancer on the faces of those affected. As facial plastic and reconstructive surgeons, we are committed to standing beside our patients throughout this process.
One of the most straightforward methods to repair a skin cancer defect is primary repair of the wound edges with sutures. This converts the skin cancer wound from a circular opening to a linear scar. Often the wound must first be made longer before repair to allow the edges to come together evenly. Typically, the final scar created is two to three times the length of the original defect. Simply suturing the edges together without extending the incision will result in unnatural appearing skin bunching at the ends of the incision. A longer scar with smooth skin edges tends to be less visible than a shorter scar with bunched edges. The direction of the repair is as important as the evenness of skin edges. Throughout the face there are natural lines that correspond to tissue elasticity called relaxed skin tension lines (RSTL). Incisions placed in the same direction as these lines blend in much better and form less visible scars than incisions placed across these lines. During primary repair of a defect, a great amount of care is taken to select the best orientation of the final scar in relation to skin lines and proximity to surrounding facial structures to minimize the visibility of the scar once healing has completed.
Healing by Secondary Intention
Secondary intention healing involves allowing the wound to heal spontaneously without suturing the edges together. During the healing time the wound needs to be cleaned regularly and ointment is typically applied several times per day to keep the wound moist. Depending on the size of the wound, healing can take weeks to months to complete, but eventually the open wound is covered with a new layer of skin that has grown in from the edges. Wounds that heal by secondary intention typically have more scar contraction and may have a lighter color or slight depression in height compared to surrounding skin. For most locations of the head and neck, secondary intention is not an ideal method of wound closure for these reasons. In specific circumstances, however, secondary intention healing may be recommended as a simple method of wound closure that does not require sutures or additional incisions.
Skin grafting involves removing skin from one portion of the body and using it to repair a defect at another location. Skin grafts can be taken as partial thickness (shaving off the very top layer of skin without an incision) or full thickness grafts (surgically removed and sutured closed). Partial thickness grafts tend to heal with significant contraction and may appear lighter in color and shinier than the surrounding skin, so they are rarely the first choice for repairing defects on the face, but they may be utilized in certain locations.
Full thickness skin grafts are the primary type used to repair facial defects. One advantage of skin grafts includes avoiding extending or placing additional incisions at the site of the skin cancer removal. The skin graft is designed to exactly match the shape of the defect. Based on the location of the cancer defect, skin is selected for a graft that has the best color, surface, and thickness match. Commonly selected sites include high on the forehead, behind or just in front of the ear, or low on the neck. The graft is removed from this location and this site is sutured closed in a fine line. The skin graft is then sutured into the cancer defect. This can be a very quick and reliable method to repair some facial defects.
Some disadvantages of skin grafts include the limited color and contour match to the skin around the cancer defect. Since the skin is taken from a different location on the body, the skin doesn’t match as well as if skin immediately next to the cancer site was used to repair the defect. A skin graft does not have any blood supply of its own and relies on new blood growth from its new location for nourishment. If there is not enough blood supply, a portion or all of the skin graft could die following placement. One factor that lowers this risk involves preventing the skin graft from moving during the healing process. Any slight movement between the graft and the surrounding skin can disrupt the delicate new vessels that are forming to nourish the graft. For this reason, a special dressing called a bolster is often placed at the time of surgery and sewn in place to prevent the graft from moving. This is typically kept for one week and is then removed in the office at follow up. Skin grafts can only be used to repair fairly shallow cancer defects because taking a very thick graft decreases the chances that it will receive enough new blood supply to survive following the procedure. Despite these limitations, for certain cancer defects of the face, a skin graft provides a very reliable and good aesthetic outcome without the need for lengthening incisions around the defect and keeps the operative time short.
Before and after repair of nasal defect by skin graft
Local Flap Reconstruction
Local flap reconstruction is the most common type of reconstruction performed for most facial skin cancer defects. This involves using skin that is immediately adjacent to the site of the cancer to repair the defect. There are numerous types of local flaps each with different designs and specific methods of movement to fill the cancer defect. The exact type of flap chosen is based on the location and size of the defect left after skin cancer removal along with the unique characteristics of the individual’s skin in that location. Essentially all local flaps involve extending incisions from the original cancer defect to allow for elevation of a flap of skin that can be rotated or advanced to cover the defect. The final shape of the scar created may have a very irregular shape rather than a straight line and the scar length may be quite a bit longer than the size of the original defect, but the goal is to re-drape the skin in a smooth manner and hide scars as much as possible in existing facial lines or shadows.
The goal of the reconstructive surgeon designing a local flap is to view the face as a whole and select the flap that will repair the defect to create the most seamless result without compromising facial symmetry or harmony. Local flaps take advantage of certain areas of the face where there is slight excess skin or skin that stretches more easily.
Local flaps have many advantages compared to skin grafts including better color and contour match. The local flap carries with it some native blood supply, so it can be designed with the best thickness to match the depth of the cancer defect. Skin color and quality is also a good match for the defect site since the skin is transferred from immediately adjacent to the defect. Typically following local flap repair of a skin cancer defect, sutures will remain in place for up to one week and will be removed in the office at follow up.
Surgical repair of lip
Reconstructing a cancer defect of the nose has many challenges and entire textbooks are written on this very subject. The nose is different from many other locations on the face because it occupies the very center of the face and holds significant aesthetic importance along with crucial functional importance with breathing. The nose has a complex three-dimensional shape consisting of overlying skin of varying thicknesses, a supporting framework of cartilage and bone, and an inner lining of specialized skin. Cancer can affect one, or all three of these layers, and each needs to be reconstructed thoughtfully to achieve an excellent functional and aesthetic result.
The same options for repair listed above exist for defects of the nose, but special considerations often exist. For skin cancer defects that involve just the outer skin of the nose, skin grafts or local flap reconstruction may be an excellent solution. The nasal skin has less laxity than skin in other regions of the face, and there is less neighboring nasal skin available to transfer to the defect as a local flap. For these reasons, local flap reconstruction of the nose is limited to smaller cancer defects in certain locations on the nose to avoid distorting the nasal shape.
Skin grafts can be used to repair superficial defects of the nasal skin without extending nasal incisions or distorting nasal shape. Selecting an appropriate donor site for the skin graft is crucial as the skin of the upper portion of the nose is fairly thin and mobile, while the skin of the lower nose is thicker with limited mobility. Forehead skin is often a good match in terms of skin thickness, quality, and color. A skin graft can be taken from the upper forehead with the incision hidden in the hairline and used to repair a defect of the nose. A bolster dressing is placed over the skin graft that is sewn in place and removed one week later in the office.
Nasal cancer defects that involve more than just the outer skin layer required more complicated reconstruction that often requires more than one procedure to complete the reconstruction. Structural support for the nose is often required in these cases to maintain good nasal breathing and cartilage grafts may be used from the nasal septum, behind the ear, or the rib cage to provide this support. Larger defects may not be adequately repaired with local nasal skin or a skin graft and require transferring skin along with its blood supply from additional areas. The two main areas used are the forehead and the cheek.
The forehead is one of the best sources of skin for large nasal reconstructions and the paramedian forehead flap (PMFF) is widely and reliably used for this purpose. This procedure requires two to three surgeries for completion. At the initial stage, precise measurements of the nasal defect are taken and a flap of skin exactly matching these dimensions is raised vertically from the eyebrow to the hairline and rotated down to cover the nasal defect. This tissue is left attached near the eyebrow to allow the blood flow at this location to nourish the flap. As the tissue heals, new blood vessels grow into the flap from the nasal side. Three to four weeks later, the flap can be detached from the eyebrow and will survive based on the new blood flow from the nose. A third surgical stage may be recommended to make fine adjustments in contour either before or after the eyebrow attachment is divided. This reconstruction is often combined with additional cartilage grafts for support and lining reconstruction with local flaps from the nasal septum or skin grafts. While this procedure requires multiple surgical steps with a period of wound healing and the inconvenience of several weeks with a bridge of tissue spanning from the eyebrow to the nose, it usually provides an excellent final result both in terms of nasal function and aesthetics.
After nasal repair by paramedian forehead flap 1
After nasal repair by paramedian forehead flap 2
For certain locations a cheek flap (nasolabial flap) can be used to transfer skin from the cheek to the nose. This is also done in two stages to preserve blood supply to the tissue being transferred and is most useful for cancer defects on the lower portion of the nose. In the first stage a flap of skin matching the size of the defect is designed from the cheek and transferred to the nose, but the base of the flap is kept in place at the cheek to preserve blood supply. The second stage is performed three to four weeks later and consists of dividing the attachment to the cheek and completing the closure of the nasal defect. This procedure can also be combined with cartilage grafting or intranasal lining reconstruction as needed.
For very large nasal defect involving most of the nose, additional reconstructive stages are required to adequately repair the entire structure of the nose. This is a complex process that sometimes involves transplanting tissue from distant sites on the body, such as the forearm skin, as a free flap that requires sewing together arteries and veins to provide blood flow to the tissue. Some patients may also benefit from a prosthetic or “artificial” nose that is artistically created to match size, shape, and color of the original nose. We work closely with our colleagues in maxillofacial prosthodontics to prepare the site for the prosthetic nose they create.
Major Facial Reconstruction
Occasionally skin cancer becomes quite extensive and can invade surrounding structures such as muscle or bone on various portions of the face or scalp. In these situations the cancer removal is much more involved and typically performed by our partners in head and neck oncologic surgery. There is usually insufficient tissue surrounding the cancer defect to perform an adequate reconstruction and additional tissue must be transplanted from distant part of the body by what is called a free flap. This procedure involves removing the required tissue (skin, muscle, fascia and/or bone) from a distant body site like the arm, leg, or back. The tissue is transferred along with its artery and vein and this is transplanted into the new site along with microscopic connection to an artery and vein in the neck. In this way blood flow from the neck travels through the artery and vein in the flap to provide nourishment. This technique is complex and requires specialized training but is an excellent way to repair large cancer defects that could not be repaired by other methods.
Scar Revision & Follow Up
All individuals affected by skin cancer of the face should have regular follow up with a Dermatologist experienced in skin cancer to watch carefully for cancer recurrence or development of a new cancer. As Facial Plastic and Reconstructive Surgeons, we also like regular follow up with our patients to closely follow the healing process after a reconstruction is performed. The healing period for all incisions takes up to one year to be fully complete. At various time points throughout the healing or even once healing is complete, additional interventions may be suggested to optimize the final outcome and minimize the scar. These interventions include topical wound care therapy, injectable treatments such as steroids, dermabrasion or laser treatment of scars or surgical revision of scar with additional contouring as needed. These are discussed in more detail in the scar revision section. Our commitment to our patients dealing with skin cancer is to produce the most natural final result possible.