Reconstructive Options for Basal Cell Carcinoma Defects in the Head and Neck Region: An Institutional Experience

Abstract

Basal cell carcinoma (BCC) is the most common skin cancer with more than 80% occurring on the face occurring mainly due to exposure to ultraviolet rays in the elderly due to cumulative exposure of the UV rays during their lifetime. Though various treatment modalities are available for the treatment of basal cell carcinomas, wide local excision is the standard line of management. However, reconstruction of facial BCC poses a challenge to the reconstructive surgeon. Over a 4-year-old period from 2017 to 2021, a total of 30 patients of head and neck basal cell carcinoma were surgically excised in our institution. We have explored all modes of reconstruction from small to large BCC defects in terms of cosmesis, form and function. Four patients underwent primary closure, 8 patients underwent skin grafting, 13 patients underwent closure by local and advancement flaps and 5 patients with large defects underwent free flap reconstruction. No flap loss was reported. None reported any functional deficit. To achieve adequate aesthetic surgical outcomes after reconstruction, knowledge of facial aesthetic regions is of utmost importance. The size and location of the defect and the presence of vital structures adjacent to the defect should be assessed to determine the kind of reconstruction that should be carried out without adversely affecting adjacent structures. For greater patient satisfaction, the method of reconstruction should be tailor made, where donor tissue resembles native tissue with good contour and texture match, suture line scars are camouflaged, and complications are nil.

Introduction

Basal cell carcinoma (BCC) is the most common skin cancer accounting for more than 90% of all malignant head and neck skin tumors and 75% of non-melanoma skin cancers [1]. Around 80% of all BCCs occur on the face [2]. It occurs mainly due to exposure to ultraviolet rays occurring mainly in the elderly due to cumulative exposure of the UV rays during their lifetime. There are various modalities of management of BCCs—surgical excision, laser excision, cryotherapy, radiotherapy, electrodesiccation or topical therapies like 5-FU and imiquimod [3]. However, the ideal treatment for BCC is complete surgical excision with adequate safety margins or with micrographic control [1]. After the lesion is excised and a surgical defect is created, careful planning is required to choose and execute the appropriate mode of reconstruction based on the knowledge and principles of facial aesthetic surgery. In small defects, primary closure is possible but in cases of large defects, local flaps like advancement flap, rotation flap or transposition flap and usually give good cosmetic results as it matches the surrounding tissue in terms of colour and texture [4]. However, defects which are not amenable to reconstruction by local flaps, a free flap reconstruction can give superior aesthetic results with improved form and function. In this paper, we explore all reconstructive options available for reconstruction of small to large sized basal cell carcinoma defects.

Materials and Methods

Over a 4-year-old period from 2017 to 2021, a total of 30 patients of head and neck basal cell carcinoma were surgically excised in our institution. All patients had undergone pre-operative punch/incisional biopsy and were histopathologically proven cases of basal cell carcinomas.

Out of those, 04 patients underwent primary closure, 08 patients underwent skin grafting, 13 patients underwent closure by local and advancement flaps (Figs. 1a–c, 2a–c, 3a–c, 4a–c) and 5 patients with large defects underwent free flap reconstruction (Figs. 5a, b and 6a–c). In two patients orbital exenteration was required. Out of those two one was a recurrent lesion and the other was a primary giant BCC with orbital invasion present in both cases. Vision loss was present pre-operatively in both. Because of the large lesion size in 5 patients, we also assessed these patients for BCC syndromes such as Gorlin-Goltz syndrome and xeroderma pigmentosum, but they were negative. In this paper, we have explored all modes of reconstruction from small to large BCC defects over a 4-year period in terms of cosmesis, form and function.

Fig. 1.

a Pre operative picture of BCC (ear), b Defect after excision c Reconstruction of ear defect with scalp flap

Fig. 2.

a Bcc in right nasal ala, b Defect after excision, c Reconstruction with superiorly based Nasolabial flap

Fig. 3.

a Bcc of cheek and adjoining temporal area, b Scalp flap mobilized to cover the defect, c Reconstruction with scalp flap and coverage of donor area with split thickness skin graft

Fig. 4.

a Bcc of forehead, b Defect after excision, c Reconstruction with median Forehead flap

Fig. 5.

a Giant Facial BCC, b Reconstruction with Free Radial Artery Forearm Flap (FRAFF), c Reconstruction with Free Radial Artery Forearm Flap (FRAFF)

Fig. 6.

a Bcc of eyelid involving orbital contents, b Defect after excision and orbital exenteration c Reconstruction with Anterolateral Thigh Flap (ALT)

Results

Out of 30 operated patients, male and females were almost equal in number with a slight male predominance (n = 16). There was a wide age range from 29 to 77 years with a mean age of 59.06 years. The most common site of occurrence was the facial skin with involvement of temporal area followed by ear, eyelid and nose with equal distribution. The most common tumour was of nodular variety where most were ≤ 5 cm and only 5 of them had dimensions > 5 cm, the highest being 12 cm. All the patients had biopsy proven basal cell carcinomas of the head and neck region. After wide local excision with adequate safe margins, reconstruction was decided based on the final defect size, location of the defect and infiltration into the surrounding structures. All lesions < 1 cm underwent primary closure without any excessive tension or tissue distortion, whereas lesions ranging from 1 to 2 cm had either primary closure (lax skin) or skin grafting where tendons or bones were unexposed. Local flaps were used as the commonest means of reconstruction with scalp flap being mostly used. Free flaps were used in giant BCCs in defects > 5 cm.

Age distribution	Total no.
< 40 years	04
40–60 years	08
> 60 years	18
Total	30

Gender distribution	Total no.
Males	16
Females	14
Total	30

Mode of reconstruction	Total no.
Primary closure	04
Skin graft	08
Local flaps	13
Free flaps	05
Total	30

Type of soft tissue flap	Total no.
Scalp flap	05
Nasolabial flap	04
Forehead flap	04
FRAFF	03
FALT	02

Surgical procedure	Total no.
Wide local excision	28
Wide local excision with orbital exenteration	02
Total	30

Site of the lesion	Total no.
Cheek with adjoining temporal area	10
Ear	06
Eyelid	06
Forehead	02
Nose	06
Total	30

Size of the lesion	Total no.
< 2 cm	12
2–5 cm	13
> 5 cm	05
Total	30

Clinical presentation	Total no.
Nodular	26
Ulcerative	02
Morpheaform	02
Total	30

All patients recovered well. No systemic complications were observed in any of the cases. No flap loss was reported. None reported any functional deficit. All margins were free from tumour pathologically in all cases and all were followed up for at-least 2 years post excision.

Discussion

Though various treatment modalities are available for the treatment of basal cell carcinomas, wide local excision is the standard line of management. As with our series, Nodular BCC is the most frequently occurring form of BCC, accounting for more than 75% of all cases. They present clinically as either superficial or ulcerated lesions and are commonly seen on actinic damaged skin [5]. Head and neck region is the most commonly afflicted zone and is the site for over 90% of nodular BCC lesions. BCC occurs more frequent in the elderly and the incidence increases with age. More than 90% of BCCs are detected in patients above 6th decade [5]. Six percentage of the patients in our series were above 60 years of age. In head and neck region, face is the most common site of occurrence of BCC due to chronic sun exposure. According to studies, nose is the most common site of facial BCC, accounting for 25–30% because of cumulative solar exposure [6]. However, in our study, cheek was the most common site accounting for 33.33%, all of them occurring above the ala-tragal line with involvement of the temporal area in some cases. Nose accounted for 20% of the total number of cases of facial BCC. Usually, males are more commonly affected due to excess sun exposure owing to their outdoor occupation. In our study, 46.67% cases were of female patients probably because of dynamic epidemiology of BCC with increasing female preponderance. There are several risk factors which have been identified for recurrence of BCC. These include size of the tumour (≥ 2 cm), location of the tumours in “H zone” of the face (representing the areas of embryonic fusion planes and includes portions of the nose, scalp, ears, and lips), recurrent lesions, presence of perineural invasion, irregular borders, and aggressive histology types (infiltrative, morpheaform, or basosquamous histology) [6]. Large tumours are often referred to as the Giant BCCs which are defined as the tumours that are more than or equal to 5 cm in its greatest dimension. It is rare for giant BCCs to occur in the head neck region, the most common location being the back. Out of total 30 patients, 5 patients (16.67%) of the patients presented with giant BCCs on the face which is double than that reported by Mahadevan et al. in their series (8%) [6].

It is of utmost importance to achieve adequate surgical margins in BCC to prevent local recurrence [7]. The margins depend on the size of the lesions, its anatomic location and infiltration into vital structures, clinical features, presence of superficial ulceration and apparent depth of invasion. It is a common practice to employ a 5 mm safe margin for excision of BCCs [7]. For our series, we took judicious margins of minimum 5 mm for lesions less than 2 cm in diameter and at least 1 cm for giant BCCs.

Studies reveal that cumulative 5-year recurrence rate of primary lesions is 4.8%, whereas recurrent lesions could re-recur at a rate of 11.6%. None of the lesions including the giant BCCs ranging in the size of 5–8 cm showed any signs of recurrence in the follow up period of maximum 5 years and minimum of 2 years’ time. We believe one of the primary reasons for not recurring is the judicious margins taken at the time of excision.

After surgical excision, closure can be achieved primarily, or reconstruction can be carried out by according to the reconstruction ladder in the form of skin grafts, local flaps, regional flaps or free flaps. Whenever possible, as with all facial surgeries, scars should be placed at the border of aesthetic facial units to provide the best camouflage. When there is disease extension and scars cannot be placed at borders of aesthetic units, they should be aligned parallel to relaxed skin tension lines (RSTLs) of the face resulting in less wound closure tension and a favourable scar camouflage [2]. For the same defect, multiple reconstructive options are available. For small lesions amenable to primary closure which had excision done outside with no mention of margins had their margins revised in our institution followed by primary closure or appropriate reconstruction. Reconstructive options range from skin grafts to free flaps. Since local flaps had the best aesthetic match in terms of tissue texture, colour and appearance with minimal donor site morbidity, they are considered to be ideal for reconstruction of small to medium sized facial BCC defects. In elderly patients, due to increased laxity and pliability of facial skin, local flaps can be used even for large defects. However, in young patients, skin is more elastic and resilient, making local flaps for large defects a challenging option. In cases of defects > 5 cm, with increased dead space which needs filling and where a bulky reconstruction is required (For example, a deep penetrating tumour of the eyelid invading the orbit and/or paranasal sinuses requiring orbital exenteration), free flap reconstruction is preferred. However, the ultimate decision of reconstruction is dependent on the surgeon’s choice and expertise taking into account the patient’s requirement. Depending on experience we have formulated a reconstrution algorithm, given later in this paper.

In our study, 43.33% defects were reconstructed using local flaps, the most common being the scalp flap in 5 patients. Nasolabial flaps and forehead flaps were used equally in 4 patients each. All our 5 cases of giant BCCs were reconstructed with free flaps in which the defects involved multiple facial subunits and local tissues proved insufficient. All the cases healed well without any report of flap loss or untoward complications.

The risk–benefit ratio and the choice of reconstruction must be explained to all patients pre-operatively. With skin grafting, though initially accepted, on late post-operative follow-up, some patients may be dissatisfied with the end results. However, since we did not use skin grafts for large lesions and they were taken up well post-operatively, we did not face patient dissatisfaction. For all other lesions reconstructed with local free flaps, all patients were satisfied with post-operative outcome including cosmesis, form and function. With a minimum follow up period of 2 years all are doing well without any evidence of recurrent disease. With our experience we have made a reconstruction algorithm which can be followed

• (A)Lesions < 1 cm—primary closure
• (B)Lesions 1–2 cm
  1. Primary closure if skin is lax
  2. Local flap
• (C)Lesions 2–5 cm
  1. Local flap if skin is lax, less depth, no excessive dead space
  2. Free flap if depth is more, excessive dead space is present
• (D)Lesions > 5 cm/lesions involving multiple facial subunits—free flaps preferred

Conclusion

The study highlights head and neck basal cell carcinomas, their reconstruction and post-operative outcome. The surgical margins must be well defined and uncompromised in order to get lower recurrence rates. We would like to emphasize the importance of the preoperative assessment of the defect size and plan a reconstruction beforehand. For greater patient satisfaction, the method of reconstruction should be tailor made, where donor tissue resembles native tissue with good contour and texture match, suture line scars are camouflaged, and complications are nil. Free flaps should be considered over local flaps for large defects for better cosmesis, form and function. Finally, we should motivate the patients for regular follow-up visits, in order to evaluate outcomes and diagnose recurrences if any, early.

Funding

No funding has been received.

Declarations

Conflict of interest

There are no conflicts of interest.

Ethical Approval

The paper has been approved by the ethical committee

Informed Consent

Informed consent was taken from the patients for participation in the study